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Question
Hello Dr. Leslie.  I have a bit of a complicated question.  I was diagnosed with IGA Nephropathy 11 years ago.  Since then, I have been under the care of a nephrologist and I get regular 24 hour urine tests, GFR, blood work, etc.  

I also have chronic migraines for which I take Topamax (50 mg 1x day).  Over the past few months, I have noticed intermittent issues with cloudy urine.  I have mentioned this to my regular physician and my nephrologist.  They have tested the urine for infection, the presence of WBCs and everything comes back normal.  I do have protein in my urine as a symptom of the IGA, but it normally produces foamy urine--not cloudy.  I have also noticed a distinct connection between the  cloudy urine and consumption of dairy products.  After much discussion, my nephrologist asked me to take a sample of urine and add a capful of white vinegar.  He informed me that if the urine cleared, it indicated that the cloudiness was caused by phosphate crystals in the urine and that it was a benign condition.  The urine clears after the addition of the vinegar--almost immediately.  

I'm writing because I also know that Topamax can cause an increased risk of kidney stones and that some kidney stones form as a result of calcium and phosphates.  What is your opinion on the intermittent cloudy urine.  Is this truly a benign issue that I shouldn't be concerned with or would you find this indicative of a potential problem down the line?

Answer
Sherri:

It should not be that difficult to find the cause of the cloudy urine.  A simple microscopic examination should be able to do this.

One test for calcium phosphate crystals in the urine is to add vinegar (which is acetic acid) and if the cloudiness disappears, then it's most likely due to calcium phosphate crystals; exactly what you've described.

Topamax causes a mild metabolic acidosis which means that it tends to make the urine become more acidic with less citrate.  This condition can increase kidney stone risk, but the type of stones are usually calcium oxalate and not calcium phosphate.  

It would be optimal if you could find another medication other than topamax for your underlying problem.  If not, you may be able to partially reduce the acidosis the Topamax usually produces by taking a Potassium Citrate tablet.  This replenishes the citrate supply and reverses the acid loak in the body putting it back into balance.  I usually recommend 2 10 mEq. tablets just before bed.  Talk to your physician about this.

It also may be a good idea to get an image of the kidneys either with ultrasound or even just a plain x-ray to make sure there are no kidney stones.  

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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