Phytotherapy Review & Commentaryby Kerry Bone, FNIMH, FNHAA

P.O. Box 713 • Warwick QLD 4370, Australia+61 7 4661 0700 • Fax +61 7 46610788 • www. mediherb.com

FNIMH = Fellow. National Institute of Medical Herbalists lUK)FNHAA = Fellow, National Herbalists Association of Australia

Phytotherapy forRecurrent Kidney Stones

IntroductionThere is some debate

as to whether commonlyused herbs can help the passage of pre-existing large kidneystones. Given the advances with modern techniques of stoneremoval, this is probably now a bypothetical issue in mostclinical situations. What is probably more relevant is whetherherbs can help prevent stone formation or assist in thedissolution (or passage) of small stones. This article will focuson the approaches to diet, lifestyle and use of herbs whichcan credibly prevent the recurrence of renal calculi. Therelevant herbs have been selected from both traditional andscientific perspectives.

Dietary and Lifestyle IssuesIn industrialized countries, about 80% of stones which

form in kidneys are composed of calcium salts and usuallyoccur as calcium oxalate and less commonly calciumphosphate. ' The remaining 20% of stones are largelycomposed of uric acid, struvite or cystine and will not bediscussed further here.

Because urine is supersaturated with calcium, crystalformation occurs readily if urine calcium rises, as when thereis fluid depletion or increased calcium excretion. Calcium isalso less soluble as the urine becomes more alkaline. Factorsin urine which inhibit crystallisation include^:

1. magnesium, which complexes oxalate2. citrate, which complexes calcium3. pyrophosphate which impairs crystallisation of calcium

oxalate.About 50% of patients with calcium stones have excessive

calcium in their urine. The most common cause of this is agenetically-determined increased calcium absorption in theintestine. Excessive urinary calcium can also be caused by adiet rich in sodium or animal protein. Low levels of citrate inthe urine is another factor, which affects between 20% to 60%of patients.^ Factors involved here can include urinary tractinfection, a high sodium intake, chronic diarrhoea, potassiumloss, excessive physical exercise and an excessively acid-forming diet (rich in high protein foods). High excretion ofoxalate in the urine is largely of dietary or genetic origin.Ironically the dietary factor most often responsible for oxalatestones is a low calcium intake. However, reducing the intakeof oxalates is probably a safer option than increasing dietarycalcium beyond normal levels.^

Lifestyle and diet are best aimed at preventing stoneformation and since the recurrence rate of stones is 75% over20 years, the following guidelines could he followed bypatients with a history of kidney stones.'

Regular weight bearing exercise will help store calciumin bones, which would otherwise be excreted in the urine.However, exercise should not be excessive since this increasesdehydration and can cause lactic acidosis, both factors in stoneformation. Fluid intake should be adequate, especially inwarm climates, but commercial drinks are to be avoided (theseare sometimes loaded with phosphate and sugar).

The diet should be based on fruit, vegetables and unrefinedcarbobydrates. Animal protein (including cheese) intakeshould not be excessive and dietary salt should be restricted.'^Fruit, which is rich in potassium and citrate, should beempbasized, together with foods rich in magnesium such asfermented soya products, legumes, nuts and green leafyvegetables. Calcium intake, specifically dairy foods, shouldbe moderate, but should also not be restricted unless thereare other reasons for this such as dairy protein allergy.Restriction of calcium can lead to excessive oxalateabsorption.*

If there is a history of oxalate stones, then foods rich inoxalate are to be avoided. These include rhubarb, spinach,strawberries, ginger, almonds, cashews and beetroot.

Treatment Strategy: Goals, Actions and HerbsHerbal treatment can augment the above measures

designed to prevent kidney stones and can also be used totreat existing stones. The regime is largely the same for thesetwo treatment scenarios. In the case of managing existingstones, treatment is aimed at passing small stones and/orgradually weakening or dissolving larger stones.

• A key herb is Crataeua, which research has shown canassist the passage of small stones and prevent the formationof new stones (see the detailed information helow). Otherantilithic herbs such as horsetail and golden rod are indicated,as are aquaretics (see below) which will render the urine moredilute (as will copious fluid intake). Dandelion leaf is alsouseful given that it is rich in potassium.

• Anthraquinone-containing herbs such as cascara andyellow dock can help by binding calcium in the urine andmaking it less likely to precipitate. The herb madder {Rubiatinctorum) was particularly used for this effect in Europe,but has now been banned due to concerns over carcinogenicity.

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Phytotherapy Review

• Infection can provide a focus for stone formation, hencethe treatment strategies for cystitis should also be followedif infection is thought to play a role. This includes immunesupporting herbs such as Echinacea root and antibacterialherbs such as cranberry and buchu. However tbere is someclinical evidence to suggest that cranberry may slightlyincrease the risk of oxalate stone formation.''

• If a stone is lodged and causing pain then urinary tractdemulcents and spasmolytic herbs such as cramp bark andwild yam are additionally indicated. The prescription-onlyspasmolytic Ammi visnaga was traditionally used in Egyptto aid the passage of urinary stones. While stones are causingdamage to the urinary tract mucosa, immune enbancing herbsand urinary tract antiseptics will lower the risk of infection.A species of oak Quercus salicina iQ. stenophylla) has beenused to treat urinary stones in Japan since 1969. Clinicaltrials have demonstrated efficacy in assisting the passage ofboth renal and ureteral

Diuretics and Aquaretic HerbsAlthough tbe term diuretic denotes all substances which

increase urine flow (and in this sense water itself is a diureticagent), modem diuretic drugs are designed to increase sodiumexcretion, since cardiac edema largely results through sodiumretention. In contrast, in herbal texts the term diuretic isoften loosely or inaccurately applied.

In particular, when a herb was taken as a decoction orinfusion, as it often was traditionally, the water consumed inconjunction with the herb would have produced an observablediuresis which might have had little to do with any diureticaction of the herb itself. Hence, many herbs have beenmistakenly classified as diuretics. Those herbs wbicb didexhibit a mild diuretic activity might have done so becauseof their mineral (electrolyte) content (see below).

Confounding the issue, the term diuretic is often used inquite a different context in herbal writings. Herbs which aresaid to enhance the excretion of metabolic waste from thekidneys are also often described as diuretics. However, a moreaccurate description is encompassed by the terminology"diuretic depurative." Examples of diuretic depurativesinclude celery and clivers. Any frank diuretic action of theseherbs is probably variable, depending on the individual, andunlikely to be outside normal pbysiological limits.

In Europe, phytotherapists have proposed that the termaquaretic might more accurately describe some herbs whichgenuinely do increase urine output. The thinking here is thatthese herbs act on the glomerulus (unlike conventionaldiuretic drugs which act further along the nephron) toincrease water excretion from the body, but their effect onelectrolytes such as sodium and potassium is largely neutral.In other words, aquaretics act by increasing fluid loss fromthe body in a physiological manner, by increasing theformation of primary urine.** The herb combination which hasbeen most studied in this context is asparagus root(Asparagus officinalis) with parsley herb {Petroselinumcrispum).^ In uncontrolled trials, this combination causedsignificant weight loss in overweight pat ients and

significantly lowered blood pressure in patients withhypertension, without changing other biochemicalparameters.'' Aquaretics have potential for the treatment ofexcessive weight, hypertension, congestive heart failure,kidney stones and premenstrual syndrome.

The mineral (electrolyte) content of herbs can oftenunderpin any observed diuretic activity. The ratio ofpotassium to sodium was found to be higher in decoctions ofherbs which are traditionally regarded as diuretics, comparedto other herbs.'" A pharmacological study concluded that thehigh potassium content of dandelion is the agent responsiblefor any diuretic activity."

Juniper is a well-known herbal diuretic, which probablyhas this property because of its essential oil, although othercompounds in the berries could enhance the diuretic effect.The infusion and essential oil of juniper berries, as well asterpinen-4-oI, were tested for diuresis response in rats.'^ Oninitial dosing, all three test substances exhibited anantidiuretic effect. However, a significant diuretic effect wasestablished on repeated doses, with tbe infusion having thestrongest effect. The 'irritant' effect of juniper oil on thekidneys was investigated in another study, since there areconcerns in the literature about its long-term use. Nonephrotoxic effects were observed in an animal study andthe authors suggested that provided high quality oil is used(distilled from the ripe berries), concerns about the kidneyirritant effects of juniper are unfounded.''^

The rationale for using diuretic herbs is sometimesmisguided in herbal texts. In particular, herbs with areputation for acting as diuretics are often recommended forthe treatment of cystitis. The obvious basis for tbis approachis to flush the infecting bacteria from the bladder. However,in tbis context, the cheapest, safest, best and most certainflushing agent is water. Any action of herhal diuretics will bemarginal compared to the flushing effect of a copious intakeof water and cannot be justified.

Key diuretic or aquaretic herbs include dandelion(especially the leaf), asparagus root, parsley, juniper andhorsetail. Other diuretic herbs used in Europe wbich appearto be effective include Java tea (Orthosiphon spp) which hasbeen tbe subject of an ESCOP (European ScientificCooperative on Phytotherapy) monograph and the spiny rest-harrow iOnonis spinosa).

CrataevaIn Ayurveda, Crataeva nurvala is highly acclaimed for its

use in the management of urinary tract disorders,'"* especiallykidney stones.''' Texts dating from the 8tb century BC recordits application in urological diseases, with stronger emphasison its use for kidney stones being recorded around 1100 AD.'^Its ancient status as the main Ayurvedic berb in urinarydisorders is now supported by pharmacological and clinicalresearch.

Crataeva significantly inhibited bladder stone formationin an experimental model in rats.''' The bladders of treatedanimals showed less edema, ulceration and cellularinfiltration when compared to controls.'^

The effect of oral administration of Crataeva on calciumoxalate kidney stone formation was studied in rats. 16 Therewas a decreased tendency to stone formation when comparedto controls due to a number of identified factors. Endogenous

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oxalate synthesis was decreased. There was also a reductionin the deposition of stone-forming constituents in the kidneysand a decrease in urinary excretion of crystalline components.One of the components responsible for this effect wasidentified as the phytochemical lupeol.'^

After treatment with a Crataeva decoction, the urine ofpatients became less lithogenic." Urinary calcium wasreduced and urinary sodium and magnesium increasedsignificantly. '•* A pharmacological study found that Crataevainfluenced small intestinal Na,K-ATPase which may in turninfluence the transport of minerals.'^

An uncontrolled clinical study ofthe effects of Crataevadecoction on 46 patients with kidney, ureter or bladder stonesnot requiring surgery found 26 patients passed the stoneswithin 10 weeks of treatment and the majority of theremaining patients experienced symptom relief."

References1. Pak.C.Y.C. 1998,'Kidney stones', Lofice/, vol. 351, pp. 1797-18012. Whitfield, H.N. & Mallick, N.P. 1995, 'Renal calculi'. Medicine,

pp. 199-2043. Burtis, W.J., Gay, L., Insogna, K.L., Ellison, A. & Broadus, A.E.

1994, 'Dietary hypercalciuria in patients with calcium oxalatekidney stones', American Journal of Clinical Nutrition, vol. 60,pp. 424-429

4. Curhan, G.C., Willet, W.C., Rim, E.B. & Stampfer, M.J. 1993, 'Aprospective study of dietary calcium and other nutrients and therisk of symptomatic kidney stones'. New England Journal ofMedicine, vol. 328, pp. 833-838

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Phytotherapy Review5. Gettman MT, Organ K, Brinkley LJ et al. J Urol 2005; 174(2):

590-594Higashi Y, Yamada H, Kobori G et al. Hinyokika Kiyo 2005; 51(3):215-223Watanabe K, Yuri K. Kinyokika Kiyo 1989; 35(5): 769-773Werk, W. 1994, 'Wasser ausleiten: elektrolytneutrai ' ,Erfahrungsheilkunde, vol. 11, pp. 712-714Beitz, G., Hippe, S.K. & Schremmer, D. 1996, 'Asparagus-P, daspflanzliche diuretikum in der Herz-Kreislauf-Therapie',Naturheilpraxis, vol. 2, pp. 247-252

10. Szentmihlyi, K., KEry, A., Then, M. et al. 1998, 'Potassium-sodium ratio for the characterisation of medicinal plant extractswith diuretic activity', Phytotherapy Research, vol. 12, pp. 163-166

11. Hook, I., McGee, A. & Henman, M. 1993, 'Evaluation of dandelionfor diuretic activity and variation in potassium content'.International Journal of Pharmacognosy, vol. 31, no. 1, pp. 29-34

12. Stanic, G., Samarzija, I. & Blazevic, N. 1998, 'Time-dependentdiuretic response in rats treated with juniper berry preparations',Phytotherapy Research, vol. 12, pp. 494-497

13. Schilcher, H. & Leuschner, F. 1997, 'Studies of potentialnephrotoxic effects of essential juniper oil (German), 'Arzneimittel-Forschung, vol. 47, no. 7, pp. 855-858

14. Deshpande, PJ. et al: Indian J Med Res 1982; 76, 4615. Prabhakar, Y.S. and Kumar, D.S: Fitoterapia 1990; 61, 9916. Varalakshmi, P. et ah J Ethnopharmacol 1990; 28, 31317. Malini MM, Baskar R, Varalakshmi P. Jpn J Med Sci Biol 1995;

48(5-6): 211-22018. Varalakshmi, P. et a\. J Ethnopharmacol 1991; 31, 67

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