Urinary Citrate, an Index of Acid-Base Status, Predicts Bone Strength in Youths and Fracture Risk in Adult Females

J Clin Endocrinol Metab. 2016 Dec;101(12):4914-4921. doi: 10.1210/jc.2016-2677. Epub 2016 Sep 27.


Context: Diet can impact on bone strength via metabolic shifts in acid-base status. In contrast to the strongly diet-dependent biomarker urinary potential renal acid load (uPRAL), the amount of renally excreted citrate integrates nutritional and systemic influences on acid-base homeostasis with high citrate indicating prevailing alkalization.

Objective: To examine the association between urinary citrate excretion and bone strength as well as long-term fracture risk.

Design and participants: Prospective cross-sectional analysis; 231 healthy children (6-18 y) of the Dortmund Nutritional and Anthropometric Longitudinally Designed Study were included, with at least 2 urine collections available during the 4 years preceding peripheral quantitative computed tomography (pQCT) of the nondominant proximal forearm. uPRAL, urinary citrate, and urinary nitrogen excretion were quantified in 857 24-hour urine samples. Data on overall fracture incidence were collected within a 15-year follow-up after pQCT measurement.

Main outcome measures: Parameters of bone quality and geometry (pQCT) as well as long-term fracture incidence.

Results: After controlling for confounders, especially forearm length, muscle area, and urinary nitrogen (biomarker of protein intake), urinary citrate excretion was positively associated with various parameters of bone quality and geometry (P < .05). Fracture risk in adult females, but not in males, was inversely associated with urinary citrate and positively with uPRAL (P < .05).

Conclusions: Although urinary citrate has to be confirmed as an integrated noninvasive biomarker of systemic acid-base status in further studies, our results substantiate dietary and metabolic acidity as potentially adverse for bone health in the long run from childhood onward.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Citric Acid / urine*
  • Cross-Sectional Studies
  • Female
  • Forearm / anatomy & histology*
  • Forearm / diagnostic imaging
  • Fractures, Bone / urine*
  • Humans
  • Male
  • Risk


  • Citric Acid