Available data on the effects of Tamm-Horsfall glycoprotein (THP) on calcium oxalate crystallization processes are apparently conflicting. With the main emphasis on calcium oxalate crystal aggregation, this review demonstrates that THP has a dual role as a modifier of crystal aggregation: in solutions with high pH, low ionic strength (IS) and low concentrations of calcium and THP itself, the glycoprotein acts as a powerful inhibitor of calcium oxalate crystal aggregation. Conversely, low pH, high IS and high concentrations of calcium and THP all favor self-aggregation of THP molecules which lowers their inhibitory activity against calcium oxalate crystal aggregation. Some patients with severely recurrent Ca stone disease excrete abnormal THPs which self-aggregate at levels of pH, IS and concentrations of Ca and THP at which normal THPs remain in monomeric form. With high Ca concentrations, such abnormal THPs become strong promoters of crystal aggregation, since conformational changes in crystal-bound THP molecules induce strong viscous binding forces which overcome repulsive electrostatic surface charges. By chelating free Ca ions, citrate reduces self-aggregation of THP molecules and turns promoting THPs into inhibitors of calcium oxalate crystal aggregation.