Ceftriaxone crystallization and its potential role in kidney stone formation

Drug-induced nephrolithiasis contributes to 1–2% of the incidence of renal calculi. We examined whether ceftriaxone at therapeutic doses could be crystallized in the urine and also explored its role in kidney stone formation. Crystallization was induced by mixing ceftriaxone sodium at therapeutic urinary excretion levels (0.5–4.0 mg/ml) to calcium chloride at physiologic urinary concentration (5 mM) in deionized (dI) water or artificial urine (AU). The results showed that ceftriaxone was crystallized with free calcium in dose- and time-dependent manner. These ceftriaxone/calcium crystals showed birefringence property under polarized microscope. Individual crystals had needle-shape (5–100 μm in length), whereas the aggregated form had star-burst and irregular-plate shape (40–200 μm in diameter) (note that the crystal sizes were much larger than renal tubular lumens). Calcium-depletion assay revealed that crystallization required free calcium as a substrate. In AU, crystallization remained although it was partially inhibited when compared to that in dI water. Finally, these crystals could tightly adhere onto renal tubular cell surface. Our data demonstrated that ceftriaxone at therapeutic levels could be crystallized with free calcium in the urine under physiologic condition. We hypothesize that tubular occlusion and crystal–cell adhesion may play important role in pathogenic mechanisms of ceftriaxone-induced nephrolithiasis.

Research highlights
► Ceftriaxone at therapeutic levels can be crystallized with free calcium.
► Ceftriaxone–calcium can be crystallized in the urine under physiologic condition.
► Crystal–cell adhesion is important for ceftriaxone-induced nephrolithiasis.