OBJECTIVE To assess the role of Tamm-Horsfall mucoprotein (THM), obtained from normal subjects (nTHM) and stone-formers (sfTHM), on crystallization of calcium oxalate (CaOx) in whole urine, and to assess the effects of N-acetylcysteine (AC) in preventing renal stone formation. METHODS A modified rapid evaporation method was used to test the effects of THM and AC on crystallization of CaOx in vitro. Animal experiments involving 30 rats and a clinical study involving 17 patients with idiopathic CaOx urolithiasis were also performed to identify further the role of AC in preventing CaOx stone formation in vivo. RESULTS The results showed that the volume of CaOx crystals was greatly reduced, by ultrafiltration, to 39.1% of untreated urine, but increased to 81.4% by adding nTHM (35 mg/l). sfTHM was a more potent promoter. AC was found to inhibit the transformation of THM and lower the crystallization of CaOx both in vitro and in vivo. CONCLUSIONS We believe that the transformation of THM is an important step in the formation of urolithiasis. AC might be a new way to prevent renal stone formation and recurrence.