To me at least, the lovely Blue Door watercolor by Andrew Wyeth is simplicity created by studied art.
Take a look at your lab report(s) and answer these questions. If you have two 24 hour urine collections this time answer from the more abnormal in every case. Here is help for reading these if you are confused. Here is more help.
But keep this in mind. I assume here you have personal physicians; that you have been screened properly to rule our systemic diseases as a cause of your stones; and that your other health issues are being looked after by your physicians. This kind of simplified approach is nice for otherwise healthy idiopathic calcium or uric acid stone formers. Others may need much more.
Section One: Initial Evaluation
Answer the questions.
The blue responses are actions you should take
- Is my urine volume less than 2.5 liters?
- No – It is high enough
- Was my collection representative of my usual life or was I showing off
- Representative
- Showing off – I should check another urine collected during my usual life
- Was my collection representative of my usual life or was I showing off
- Yes – Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
- No – It is high enough
- Is my urine calcium above 200 mg?
- No – It is not high enough to increase risk of stones
- Yes – It is high enough to increase risk of stones
- Is my urine sodium above 100 mEq (1500 mg)
- Yes – Lower my sodium intake to below 100 mEq (2300 mg); 1500 mg is ideal
- No – My sodium intake is not high
- Do I eat a lot of sweets – sugared foods?
- Yes – Reduce my sugar intake as it increases urine calcium
- No – My sugar intake is not high
- Do I eat at least 1000 mg of food calcium daily?
- Yes – People with hypercalciuria need diet calcium for their bones – continue this diet
- No – I need to eat at least 1000 mg of diet calcium daily
- Is my urine sodium above 100 mEq (1500 mg)
- Is my urine oxalate above 35 mg?
- No – My urine oxalate is not very high
- Yes – My urine oxalate is high enough to increase risk of stones
- Reduce high oxalate foods using the lists on this site
- I need to eat at least 1000 mg of diet calcium daily
- Is my urine oxalate above 80 mg?
- No – I can try diet to lower my urine oxalate
- Yes – My urine oxalate is so high my physician needs to review the matter and decide what to do
- Is my urine citrate below 400 mg?
- Yes – It is low enough to raise risk of stones
- Is my blood potassium low or do I take diuretics?
- No – It is not low enough to raise risk of stones
- Yes – It is low enough to raise risk of stones
- Is my urine pH below 5.5
- Yes – My urine pH is low enough to pose a risk for uric acid stones
- Is my uric acid supersaturation above 1?
- No – Is my urine volume high?
- Yes – High volume is protecting me against uric acid stones
- No – Uric acid may be crystallizing; Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
- Yes – Use beverages that provides supplemental alkali to raise my urine pH
- No – Is my urine volume high?
- Is my uric acid supersaturation above 1?
- No – My urine pH does not pose a risk of uric acid stones
- Yes – My urine pH is low enough to pose a risk for uric acid stones
Select and print this list
Circle the actions you need to do and pin the list up where you will see it
- I should check another urine collected during my usual life
- Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
- Lower my sodium intake to below 100 mEq (2300 mg); 1500 mg is ideal
- Reduce my sugar intake as it increases urine calcium
- I need to eat at least 1000 mg of diet calcium daily
- Reduce high oxalate foods using the lists on this site
- My urine oxalate is so high my physician needs to review the matter and decide what to do
- My physician needs to provide potassium supplements
- Use beverages that provides supplemental alkali to raise my citrate
- Use beverages that provides supplemental alkali to raise my urine pH
Get a follow up 24 hour urine test when all of the actions are in play
Section Two: Follow up Evaluations
Here is what to do when you have a follow up test
First answer the questions in Section One.
Then answer the questions here in Section Two
The blue responses are actions you should take
- Do I know what my stones have been made of?
- Yes – Look at the supersaturation(s) related to your stone(s); call these your relevant supersaturations
- No – All three supersaturations may be relevant
- Have all of my relevant supersaturations fallen by half?
- Yes –
- Am I still forming new stones
- No – Stay on my treatment and get another follow up in one year; if new stones form get it sooner
- Yes – Am I sure this 24 hour urine reflects my usual life?
- Yes – I may need medications; see my physician
- No – Get another 24 hour urine within the next 6 – 12 weeks
- Am I still forming new stones
- No – Go back over the blue actions in section one
- Is my uric acid supersaturation one that has not fallen by half?
- Yes
- Is either blue action 2 or 10 in section one above suggested?
- Yes – Do the blue actions suggested in section one and obtain a new 24 hour urine
- No – Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine
- Is either blue action 2 or 10 in section one above suggested?
- No – Either my calcium oxalate or calcium phosphate supersaturation has not fallen
- Are any of blue actions 2 – 9 in section one suggested?
- Yes – Do the blue actions suggested in section one and obtain a new 24 hour urine
- No – Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine
- Are any of blue actions 2 – 9 in section one suggested?
- Yes
- Is my uric acid supersaturation one that has not fallen by half?
- Yes –
Select and print this list
Circle the actions you need to do and pin the list up where you will see it
- Stay on my treatment and get another follow up in one year; if new stones form get it sooner
- I may need medications; see my physician
- Get another 24 hour urine within the next 6 – 12 weeks
- Go back over the blue actions in section one
- Do the blue actions suggested in section one and obtain a new 24 hour urine
- Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine
Excellent! Concise and easy to follow. Allows me to be more proactive with my doctor.
Thanks, Kim. Regards, Fred Coe
what is Dr. Coe’s email address, I would like to get in touch with him to share my recent lab reports and seek opinion in how to proceed.
Hi Ernie, My email address is flcoe@uchicago.edu. Regards, Fred Coe
When recommending fluid intake, it would be useful to provide ounces as well as liters for those of us who have yet to internalize the metric system.
Hi Jeff, Thanks; I will make that change. All the best, Fred
I have never seen a lab report.
I have never had any symptoms that I know of.
I am trying to follow the high calcium diet including 500gm of calcium (TUMS) with each meal.
Hi Robert, Thanks for your comment. Regards, Fred Coe
Dear Dr. Coe,
Thank you for this article. I will be using this as a guide when I get my next 24 hour urine report. It is concise and to the point. Very readable. I truly appreciate you sharing all of your valuable information and research. This website is definitely one of a kind, and I am so glad to have discovered it. It is apparent in every article that you write that you both understand and care about your readers and the plight of the kidney stone patient. I have yet to find a doctor in my area that makes me feel like there is any kind of treatment besides ‘drink water and hope for the best.’ However, I am seeing a new nephrologist who is the head of the kidney stone prevention center at UCLA tomorrow morning and will be bringing a copy of your article “How to be a Successful Kidney Stone Patient” with the treatment cycle highlighted and ready to share. You have provided me with the knowledge and confidence to be more proactive as I seek help.
Again, thank you!
HI,
I just got my litholink report back. SS CaOx at 9.46 and urine calcium 334, volume 1.6 liters, urine oxalate 35mg, ss CaP 1.74, citrate 991, ph 5.8, history of calcium oxalate stones. 6 over the past 20 years.
I read some of the notes above but am a bit confused as to what is the suggested corrective course based on these results. I also have been taking 4,000 iu vitamin d daily for low vitamin d levels. any thoughts/advice would be greatly appreciated.
Marc
Hi Marc, Well, you have a very high urine calcium excretion, a low urine volume, a modest urine oxalate and very high SS with CaOx of over 9 and also high for CaP = you do not need much SS to crystallize CaP. The obvious move is to double the urine volume. The high urine calcium is presumably idiopathic, unless you have a systemic disease – your physician needs to be sure about that. Next, urine calcium is very sensitive to salt intake which is urine sodium excretion. Take a look at yours. If it is above 65 mEq daily (1500 mg of sodium) lower it as much as you can. LIkewise look at your protein intake (PCR); if it is above 1, lower it. Retest. IF SS remain high despite double the volume, low sodium and reasonable protein consider thiazide – from your physician. An alternative to thiazide would be potassium citrate. Let me know. Regards, Fred Coe
Thank you so much for the prompt response and amazing information. your web site and commitment to these issues is unbelievable. other info from litholink that you mention above. “Our records do not show the use of calcium supplements, confirm clinically as calcium supplements can cause hypercalcuria. High urine calcium cannot be ascribed to high sodium (98
mmol/d) or protein intake (PCR = 0.9 g/kg/d). Our records do not report that thiazide has been prescribed. Consider use of thiazide. If prescribed recheck at 6 weeks. Monitor serum potassium as appropriate”
Hi Marc, As you may know, I founded Litholink and sold it to LabCorp in 2006. The algorithms that generated the comment you quoted were programmed by me and John Asplin, so that may account for why my comments and the Litholink report tend to agree. If you have such high urine calcium with so low a sodium intake, I would be certain about primary hyperparathyriodism or other diseases. Were both your serum PTH and serum calcium = fasting – in the normal ranges?? Regards, Fred Coe
thx again.. i had blood labs about 2 weeks ago, fasting, my thyroid panel was tsh 1.59, t4 7.4 and t up 34.3. not sure i have ever had serum pth or serum calcium tested..
Hi Marc, I am sure you have; just enquire and be sure it was fasting. Your urine calcium is quite high for such a modest sodium intake, and if there is something more it is important for your physicians to know about it and get you the best possible treatment. Regards, Fred Coe
Hi Dr. Coe.
I just checked and both fasting serum calcium is 9.5 and PTH was 82.
Hi Marc, The high PTH with normal calcium is common with low calcium diet or reduced serum 25 vitamin D. It is not a sign of primary hyperparathyroidism. Regards, Fred Coe
Dr. Coe,
I had a GIST tumor in the antrum of my stomach which was approximately 5cm. It was benign, but the treatment for it included resection via a rouxen Y laproscopic surgery. I’ve recently read the following article from NIH (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4249680/) which, according to the beginning abstract shows a 25% increase in urinary oxalate, a 30% decrease in urinary citrate, and reduction in urine volume by half a liter. Can you tell me what supplements I might take which would counter the effects of these increases in oxalytes and decreased in citrates? Would a calcium citrate and a magnesium type supplement assist? What probiotics might you recommend for me? Nobody I’ve talked with has really given me decent information on how to combat the changes from my surgery. I’ve also asked for a 24 hour urine test from my urologist. I was diagnosed last week with a 3mm kidney stone, which I don’t believe has passed, but my CT scan showed no new stones, so I want to get my levels balanced as quickly as I am able. I have also increased my water intake to consistently higher levels. Any advice you have for me would be GREATLY appreciated! Also, thank you for your information! It is extremely informative!
John J ONeill
Hi John, It is indeed true that these procedures will increase urine oxalate, lower urine citrate and raise risk of kidney stones. The approach is as you said, obtain 24 hour urine testing, find out what abnormalities are present in your specific instance, and take steps to reverse them. The general averages from the paper you mention are not a guide to actual treatment for one person. The basic approach to prevention is always the same: Find out the crystals in your stones if you can, get 24 hour urine testing, measure the supersaturations in your urine with respect to the crystals in your stones, and lower them by half, whether with water, measures to lower urine oxalate, raise urine citrate or whatever seems best in your case. Regards, Fred Coe
Hi Dr. Coe,
I experienced my first kidney stone in March of this year. The CT showed an additional 8 stones, 4 in each kidney. The largest approximately 3×6 mm. Stone analysis determined a calcium oxalate stone. 24 hour urinalysis through Litholink provided the following:
Volume- 4.31
SS CaOx- 3.66
CA 24- 231
Ox 24- 45
Cit 24- 1005
SS CaP- .54
pH- 6.569
Ss UA- .07
UA 24- .421
Hopefully that’s enough of the values for you to give me your thoughts. My urologist has recommended shock wave lithotripsy for the larger stone in my right kidney as he thinks it is too large to pass. I’m hesitant. I don’t like the idea of general anesthesia. I’ve already had surgeries to remove my appendix and gallbladder. I’m also afraid of damage to the kidney. In addition, I have Celiac disease and Hashimotos and have been gluten free for just over 2 years.
I would really appreciate your insight on how to proceed.
Thank you!
Hi Hulda, with your 4.3 liters of urine volume you have little immediate stone risk – your SS values are low, including that for CaOx. But perhaps that volume is not a constant feature of your real life. You have a moderately high urine calcium, enough to raise stone risk, and a hefty urine oxalate. Perhaps your diet is low in calcium and raising your urine oxalate; perhaps your diet oxalate intake is high. I do not see our urine sodium, perhaps it is high (above 100 mEq daily and could be lowered. You have a malabsorption state, and this can raise urine oxalate. These are all ideas for your physician and you to think about. Ideally your diet will have 1000 mg of calcium – with meals, oxalate intake is kept low, and sodium likewise to keep urine calcium low. As for the stones, perhaps flexible ureteroscopy would be better than SWL given a lot of stones. Because I do not really know your clinical situation, there are a lot of ‘perhaps’ but you know, and can fill in the blanks. Regards, Fred Coe
Hi Dr Coe,
Thanks so much for your response!
My sodium was at 78 and that urine output is constant. I drink a lot of water and some coffee. I was eating a low calcium diet as I was not able to tolerate dairy after my celiac diagnosis. I can tolerate it better now and have made that correction. I’m also reducing sodium. I was eating a lot of cashews and have cut them out completely.
My Dr is only concerned about the large stones. The remaining are 1-2 mm and he feels I can pass them.
I feel a bit stuck as to what to do. I’m a mother of 3, my youngest is 4 and we have a beach vacation scheduled at the end of the month. I’m hesitant to have any procdure done so close to our trip on case I have complications. My husband would like to have it taken care of before we go so as to avoid an incident while out of town.
What are your thoughts on the likelihood of a 3×6 stone being able to pass. If I were your patient, knowing what you know, what would you recommend?
Thank you again!
Hi Hulda, I am glad you have reduced your oxalate intake and that you maintain a high fluid intake. Long term you will need calcium, at least 1000 mg daily for your bones, and there are ways to do that. Symptomless stones are not in any way an indication for surgery. Surgery is just that, and the stone may or may not pass or cause a need for an ER visit or even a surgery. But a surgery to preemptively avoid a stone event is a sure thing: Procedure, and all that is involved. Assuming there is no significant pain, obstruction, bleeding of consequence, or infection presumed to be in the stones, there is to me no need to do anything. If you were my patient and those were the facts that would be my suggestions. Regards, Fred Coe
Thank you so much for your insights…this has been very helpful!
Hi Dr. Coe, I wanted to make sure I understand this correctly–an over the counter potassium citrate in bulk is a reasonable price–it says “275 mg serving = Potassium Citrate 99 mg.” I read elsewhere that 99 mg = about 2.53 mEq. Is that correct? Also, I had/have CaOx stones, my urine oxalate with a diet change is now 21 (down from 80 a year ago) and my other values are all normal. However, my urine pH came back as 6.491, and I would like to nudge that up a bit. How much of this bulk supplement should I take? Thank you for your help.
Hi Peter, The usual potassium citrate pill is 10 mEq so this is a very small dose size. But why would you want a higher urine pH? This one is plenty high! I would add nothing. Regards, Fred Coe
Thank you so much Dr. Coe for your fast reply, and for all the very helpful information you and your colleagues have taken the time to make available. I’m glad my pH is OK, and I’m happy not to have to worry about it, and just stick with the diet guidelines you suggest, which I have followed carefully–especially getting plenty of calcium–which reduced my urine oxalate from 80 to 21–something my urologist said he’s never seen just through a change in diet. (As I learned, my previous diet was primarily the highest oxalate foods!) My question reflected my confusion trying to understand my “LithoLink” 24-hour urine report, which has my pH of 6.491 indicating “increased risk for stone formation”, with a reference range of 5.8-6.2. I thought that the higher the number, the more alkaline, the less stone formation risk, with 7 the point of neutrality–so I thought I might need to become more alkaline. Thanks again for all your work and your help. Take care.
Dr. Coe,
Thank you for your amazing website! It is simply a mine of information. My husband has been struggling with kidney stones for the past year (he just had his 1st lithotripsy last week), and recently got back his 24 hr lab results: Urine 2.6 L, pH 6.1, Calcium 41.6mg, Sodium 98.3mEq, Citrate 317mg, Oxalate 173.9mg, Uric Acid 608.4mg, phosphorous 1170mg, potassium 86.6. His urologist simply told him “your citarates are mildly elevated, so cut high oxalate foods out of your diet, and come back in a year!” But based on my readings here, that doesn’t seem like enough. We were thinking 800mg calcium and 20mEq citrates in addition to lowering food oxalates. I should mention that due to excessive migraines (3-4) a week, my husband has had to cut dairy completely out of his diet, which I am sure is contributing. He also eats a relatively low carb diet. I am wondering if it is more appropriate to transition back to a more traditional diet (minus the diary, of course), or stick with his current diet and add all the citrate supplements and low oxalate foods…. We just didn’t get a lot of good guidance from the urologist! Thoughts? And thank you!
Hi Cindy, I agree that his urine oxalate is in a very abnormal range. If you have copied correctly 174 mg/day of urine oxalate poses a danger of kidney damage. I am sure his personal physicians are also quite concerned. I would indeed reduce oxalate foods to very low levels and also add some calcium containing foods to each large meal – no supplements – and repeat this very promptly – in a week or two. If his urine oxalate level does not fall immediately below 80 or less I am sure his physicians will want to arrange for specialized consultation concerning this oxalate level. I cannot overly emphasize that this high a urine oxalate is potentially worrisome and needs attention and remedy. Regards, Fred Coe
Thank you so much for your response! I checked his report and his oxalate readings are truly that high. And his urologist is truly unconcerned. We are increasing his calcium and lowering his oxalate foods, and are trying to get in with a nephrologist. Hopefully we can get this taken care of soon! Thank you again!
Hi Cindy, I cannot enough emphasize the need to recheck another urine and if it is the same have someone expert in this problem take the proper steps. In the meantime, have him eat a reasonably high sodium intake – I know that sounds odd but it is accurate – and avoid NSAID type drugs and any kind of dehydration; no diuretics of any kind. High oxalate conditions are dangerous and need resolution. Regards, Fred Coe
Dr Coe,
Thank you for all of this information. How do I get an appointment with you? I stumbled upon your page after my urologist here in AR said I probably need to be referred to a specialist. I am currently 33 years old (female) and had my first kidney stone removal as a child at the age of 16. Since then, I have produced a mass amount of kidney stones (60+). I have had over 10 lithrotripsies and several other kidney stone related surgeries. I am averaging at least one surgery per year, for the last 7 years. My stones are calcium oxalate and I am taking potassium citrate and have for the past 6 or 7 years. Please help. Thanks so much!
Brooke
Hi Brooke, I practice at University of Chicago and you can just ask my secretary Kathleen Dineen – 773 702 1475. I will email you as well, so she gets a copy. Regards, Fred Coe
Hi Dr. Coe,
I just got my 24 hr urine test back. My Doc prescribed hydroclorothiazide 12.5 mg once a day. I am apprehensive to take medicine. He also said reduce sodium and increase fluid. I enclosed some of the results. Is there anything else I should be doing to reduce my stone risk ? Thanks,Kelly
Ph 6.372
24 Hr Citrate 963
24 Hr Oxalate 36
24 Hr Uric Acid 0.691
24 Hr Calcium 284
Urine Volume 1.78
Supersaturation Caox 7.77
Supersaturation Cap 2.58
Supersaturation Uric Acid 0.37
Hi Kelly. Your doctor seems quite reasonable – what was the urine sodium?? You are hypercalciuric, and it would be good to raise your diet calcium intake to 1,200 mg and drop the sodium intake below 2000 mg, and see what your SS and urine calcium do. The drug would work even better if you lower your sodium and refined sugar intakes and perhaps might not even be needed. The urine oxalate may fall a lot with the high calcium intake. The drug is a reasonable choice, and if diet calcium sugar and sodium changes and lots of water are not enough you may well want to use it. The goal is for those supersaturations to fall at least by half, and your urine calcium to go below 200 mg/d and oxalate below 25 mg/d so you have a clear goal. Regards, Fred Coe
I have experienced over 10 CaOx renal stones since 1970. Two would not pass and were treated surgically. Had left ESWL last week for 2 stones (5.4 & 7.2 mm) that were about 3 & 5 mm size 4 years ago. I have been on a low salt, low oxalate and increased calcium diet for years. I have the results from my 24 hr urine collected before the ESWL and the lab report on the stone that passed in August. My urologist has reviewed the urine results and does not recommend any change to my treatment plan. How can I arrange a personal consultation for Dr. Coe the review and comment on the results? I would prefer a reply to my email address. Thanks.
Hi Wayne, I will reply privately via your email. Regards, Fred Coe
My coder is trying to convince me to move to
.net from PHP. I have always disliked the idea because of the
costs. But he’s tryiong none the less. I’ve been using Movable-type on various
websites for about a year and am nervous about switching to another platform.
I have heard very good things about blogengine.net.
Is there a way I can transfer all my wordpress posts into it?
Any help would be really appreciated!
Hi Bernard, I have no experience with this. I did a small site on Google and like it, but it is personal and does not have the utilities this one needs. Regards, Fred Coe
Hi Dr. Coe, someone else asked pretty much the same exact question I had, but I didn’t see an answer. I’ll just say it like they did and hope you can please clarify it. Thanks much
I am trying to “understand my “LithoLink” 24-hour urine report, which has my pH of 6.491 indicating “increased risk for stone formation”, with a reference range of 5.8-6.2. I thought that the higher the number, the more alkaline, the less stone formation risk, with 7 the point of neutrality–so I thought I might need to become more alkaline. Thanks again for all your work and your help. “
Hi James, There are two main calcium stone types – calcium oxalate and calcium phosphate. The former are indifferent to pH; the latter arise when pH is increased because the phosphate component takes on 2 negative charges with higher pH and they are required for binding with calcium. I do not know where you were told a higher urine pH prevents stones, it does not. The reason potassium citrate is used is to increase urine citrate, and an unfortunate byproduct is a rise of pH. I hope this is helpful. Regards, Fred Coe
Thanks Dr. Coe. My 24 hr. urine test was done by the company “Litholink” and ordered by my urologist. Urine pH was one of the many things tested, and on their scale of ‘decreased/increased risk for stone formation’ their reference range for pH is 5.8-6.2. My particular pH was 5.0, and according to their graph, that increases the risk of stone formation. Their written recommendation for my ‘very low urine pH’ is to treat with potassium citrate, to raise it. So doesn’t that mean, according to them anyway, that a higher pH will lower the risk? (My stone was 90% calcium oxalate and 10% uric acid.)
Hi James, I wrote that Litholink report algorithm with John Asplin. The low pH can cause the uric acid component in your stone and treatment with potassium citrate is indeed a good idea. The increase of urine citrate – if any – will possibly reduce for calcium oxalate as well, but there may be other factors for that part such as urine calcium, oxalate, or volume. If so they all need treatment. Regards, Fred Coe
I got my results back from Litholink on my 24 hour urine. I am confused as to whether or not I should be taking Calcium. My urine volume was very low at 0.69, SS CaOx is 14.70, not a typo. Urine calcium is 127. Urine oxalate is 38. Urine citrate is 958. SS CaP is 3.95. Urine ph is 6.752. SS uric acid is 0.28. Sodium is 120. The Nurse Practitioner called today and said to just drink more fluids. I am thinking based on these results that I should be on a low oxalate diet and increase fluids. I am not sure if I should add OTC calcium or not. What do you think based on these results. I might add that I am an RN and have been a nurse for 23 years. I am 50 years old and have had 8 kidney stones over the last several years, approximately every other year. Thanks for the reply and your website is great.
Hi Patti, Your urine volume is surely a serious liability. Calcium and citrate are not risk factors in you – you discovered that from the article. Urine oxalate is a bit high. You do not mention the type of stone you form, but your CaP SS is actually as bad as your CaOx SS: It takes about a SS of 4 – 5 to produce CaOx stones but for CaP anything above 1 will do. Like everyone who has a skeleton you should have 1,000 to 1,200 mg of diet calcium daily preferably from food. I would do that before worrying about an oxalate list. Here is my best on that. Get another 24 hour urine on fluids – lets do 2.5 liter urine or 3 liters fluid intake – and high diet calcium. Be sure and have the high calcium with the meals that will have substantial oxalate – the larger meals. Supplements are alright but food calcium is better. IF calcium and fluids are not enough to bring the SS down, then lower diet sodium – below 100 mEq preferably 65 mEq – the present US ideal intake. Regards, Fred Coe
Will adding in the recommended beverages to increase citrate affect urine pH? My urine citrate hovers Just below 400 so I would like to raise it some but my urine pH has been at or just above 6.2 on my last few Litholink reports.
Hi Stephanie, When citrate is low be sure and think about all causes: Low potassium inadequate servings of fruits and veggies- 5 or more a day, and GI disorders. If you need more citrate, be sure you know why. Ask your physician or look at your labs. Is your supersaturation now half or less of what it was before you began treating yourself; I mean supersaturation with respect to the crystals in the stones you form. If it is, 400 mg/day of citrate is just at the point where stone risk begins. Regards, Fred Coe
Hi Stephanie,
It might increase your urine pH a bit, but it is important to get your citrate levels up. If you have high pH levels, but your urine calcium level is within normal limits and you are drinking enough fluids to produce 2.5 liters of urine you will be in good shape. Hope this helps-
Jill
Dr. Coe and colleagues, I must first extend my deepest thanks for all of your stunning work throughout this website. It is truly a one-of-a-kind resource for patients (and probably not a few doctors!), and your passion for the subject shines through on every page. From the bottom of my heart, thank you. I apologize in advance for the length of this comment; much of it consists of test results that you may skip or skim as appropriate, and I have tried to keep the rest as brief as possible.
I am a patient presenting with a recurring CaOx stone condition, which has troubled me on and off for a decade or so now. I produce stones in both kidneys, but particularly on the right; they seem to form quite slowly, tend to be smooth and round, and always pass while still relatively small. Most of them don’t seem to cause any pain for some reason, and I’ve passed at least a few as large as 3-4mm without even noticing. Unfortunately, every so often my luck runs out and I experience the typical pain and difficulty while passing one, usually as it nears the UVJ. This has landed me in the ER multiple times, most recently last month, and I have resolved to get serious about prevention to ensure that there will not be a next time. As such, I recently had my first 24-hour urine panel done (the “2, 24 hour Urine Panel” from Litholink).
The reason I make this humble request for a few moments of your attention, rather than satisficing myself with the trove of expert knowledge offered throughout the site, is that my Litholink results are a bit puzzling, and my doctors and I aren’t entirely sure what to make of them–I gather I’m a bit of an unusual case. I can think of no obvious reason for this: I’m a 32-year-old male in generally fine health, and my medical history is blessedly devoid of anything interesting. I have had occasional problems with IBS, my liver is mildly fatty yet appears otherwise healthy, and I seem to be deficient in Vitamins B12 and D, but that is virtually the entire extent of my health concerns apart from the kidney stones. I certainly have never had any other detectable renal or urological issues.
The stones come in clusters, with years sometimes passing uneventfully and with no detectable stones on my ultrasounds, then a substantial crop suddenly appearing all at around the same time, likely occasioned by lifestyle-related shifts in daily urine volume. The stone that most recently landed me in the ER was 3x2x2mm, 95% Whewellite and 5% Apatite, from the right kidney; as usual, the resulting CT scan revealed that I currently have at least two other stones in that kidney, though these are thankfully “punctate” at present. Some weeks after passing that stone, I did my Litholink urine test, with the following results. (Note that, at the instruction of my urologist, I spaced the two 24-hour collection periods about a week apart. I think I did a pretty good job of capturing what has recently been my usual behavior with respect to fluid intake and everything else; as you’ll see, the fluid intake fluctuates quite a bit, and as it so happened, the first collection period captured a very typical low-flow day for me, whereas the second collection period captured a typical high-flow day. This wasn’t planned as such, but should prove instructive. Obviously, I have taken care to ensure that there are no typos and that the numbers are presented in the correct order on each line.)
Vol 24: 1.48, 2.89
SS CaOx: 2.95, 0.65
Ca 24: 51, “less than 43” (too low to measure!)
Ox 24: 30, 32
Cit 24: 370, 381
SS CaP: 0.48, 0.10
pH: 6.412, 6.932
SS UA: 0.28, 0.05
UA 24: 0.468, 0.457
Na 24: 136, 114
K 24: 33, 36
Mg 24: 48, 40
P 24: 0.591, 0.433
Nh4 24: 25, 22
Cl 24: 134, 109
Sul 24: 17, 11
UUN 24: 4.46, 3.75
PCR: 0.7, 0.6
Weight: 54 Kg
Cr 24: 1490, 1553
Cr 24/Kg: 27.4, 28.5
Ca 24/Kg: 0.9, “less than 0.8”
Ca 24/Cr 24: 34, “less than 28”
The results from the high-flow day are, of course, quite heartening–the supersaturations in particular can be taken to mean that I would be able to avoid ever forming any further stones simply by maintaining that level of flow on a consistent basis, yes? That would seem to be cause for celebration, and perfectly sufficient basis for a wonderfully simple treatment plan consisting of nothing other than maintaining a daily urine volume in the neighborhood of 3 liters. However, my doctors and I find the numbers from the low-flow day puzzling, and possibly worrisome. With SS CaOx 1.0, but these numbers seem highly unusual for such a prolific stone former as I am.
I can’t help but wonder what strange thing my body is doing to cause such an unusual result. If it’s something benign or merely idiosyncratic, that is one thing; however, I’m starting to wonder whether it may be a sign that something else demands correction in addition to the urine volume. If anything jumps out at you based on the above results, I would really love to know your thoughts. I also wonder whether this is a sign that I should more thoroughly revisit the possibility of systemic diseases, which my doctors have never considered likely enough to justify more than a somewhat cursory investigation. If it helps, I do have a serum metabolic panel, taken during the recent ER visit and processed at the hospital lab. Here are the numbers:
Serum Sodium: 138
Serum Potassium: 3.6
Serum Chloride: 103
Serum Carbon Dioxide: 27
Serum Anion Gap: 8
Serum Blood Urea Nitrogen: 8
Serum Creatinine: 1.13
Serum Glucose: 94
Total Serum Calcium: 9.4
Total Serum Protein: 7.3
Serum Albumin: 4.3
Total Serum Bilirubin: 0.9
eGFR: 86 (non-African-American)
Serum Alkaline Phosphatase: 51
AST/SGOT: 25
ALT/SGPT: 35
Serum Lipase: 133
In addition to the above, another recent blood test found a serum uric acid of 6.9. I don’t have serum phosphorus, magnesium, or pH numbers, but do have a variety of other recent blood measurements; please ask if there are any you’d like to know, and I will provide them if that might help.
Thank you so much for everything, and I do apologize again for the length of this comment. If you could offer even just a few quick thoughts on my situation, that would go quite a long way indeed toward helping me feel that I may finally be able to get this all under control. Best regards to all of you!
Hi Justin, Your labs show a pathologically low urine calcium and I suspect inadequate nutrition. Your protein intake is low, so is your urine phosphorus and sulfate. Ask you physician to consider limited medullary sponge kidney – affecting only a part of the kidney. Likewise, I suspect inadequate calcium intake. Your creatinine/kg body weight suggests very low body fat stores – is there an eating problem here. These are just thoughts for you and your physicians to consider. Regards, Fred Coe
Sorry, slight glitch in my comment from a few minutes ago: the end of the paragraph after the first batch of numbers should read “With SS CaOx under 3.0, Ca 24 of 51 and Ox 24 of 30, isn’t it a bit ridiculous that I would consistently form these large crops of CaOx stones? I know that crystal formation becomes possible at any SS over 1.0, but these numbers seem highly unusual for such a prolific stone former as I am.” Alas, the script that processes the comments doesn’t seem to be able to deal with less than/greater than signs.
Hi Justin, I have already mentioned one possible way you might have formed stones. Another is periodic very low urine volumes, or perhaps spells of vomiting or diarrhea. Consider if these are possible. You are right = something raised supersaturations, created stones, and is gone. Regards, Fred Coe
Many thanks for your consideration and suggestions. I’ll respond to both of your comments here, and will try to keep it brief. The MSK suggestion is interesting, and I will follow up on that, but at a glance it seems that in a case such as mine the only recommendation for it would be to keep on top of fluid intake as I’ll already be doing, so even a positive diagnosis there wouldn’t necessarily seem to impact the approach to treatment. The Litholink report briefly raised the spectre of RTA due to the Cit 24 and pH, but it seemed a bit dubious, so I am heartened not to see you ringing any major alarm bells there.
As far as the nutrition goes, I do have some work to do on that, and I can confirm that I do tend to get inadequate diet calcium as well as relatively little protein. I know I should correct this, but I didn’t realize it could contribute to stone formation even in the absence of elevated urine calcium levels–are you saying that excessively low urine calcium actually increases stone risk? If so, I’d appreciate if you could point me toward where that might be discussed, especially as I can’t help but feel concerned that any correction of the low urine calcium will correspondingly raise my supersaturations and therefore increase my stone risk. You’re also quite right about the low body fat, but I can’t seem to do much about that, as I’m just naturally very skinny, and my doctors have never thought there was any pathology there. I don’t generally tend to get spells of vomiting or diarrhea, and my urine volumes hardly ever fall very much below the 1.5 liters seen on the low-flow day of my Litholink test, though I can say that in the periods leading up to stone recurrences, my urine volumes are probably tending to stay around the lower end of that range for weeks or months on end. Given the numbers I’ve shown you, could that be enough to explain the recurrences, or must there also have been some other factor spiking supersaturations beyond the levels seen on the low-flow day of the recent test?
The Litholink report flagged my low citrate, high pH, low magnesium, and low phosphorus as stone risk factors. In addition to keeping my fluid intake on track and making general dietary improvements, am I likely to need to place any special emphasis on correcting any of those? And one final question: given that my oxalate levels seem perfectly fine, am I free to select relatively oxalate-rich foods as I make the dietary modifications? It would be nice to have that additional freedom as I tackle the process of improving my nutrition. Thanks once again for all your help!
Hi Justin, This is becoming complex, and I lack sufficient knowledge of your actual medical situation to go into further detail. Please feel free to share any of my remarks with your physicians, and they will do with them what they wish. But only they can actually take responsibility for your care and I fear becoming a nuisance to them or, worse, an inll informed spectator. Regards, Fred Coe
Understood. Thanks in any case for taking the time to consider my situation, and of course, for everything else you do!
Dr. Coe;
Could you give me your opinion on my 24 hour urine results. A little history: I am 59 years old and have had Calcium Oxolate stones since the mid 1980’s. At that time I was told I have MSK in my left kidney..all of my stones come from the left kidney, right one never shoes any on scans. In the late 1990’s, I was diagnosed with Ulcerative Colitis. I’ve only had one “flare-up” since then and it is easily brought under control with medicine. I currently take no medicine for this. Here are my results. Thanks.
Volume 3.09
SS CaOx 3.18
Urine Calcium 248
Urine Oxalate 24
Urine Citrate 679
SS CaP 0.44
pH 5.976
SS Uric Acid 0.41
Urine Uric Acid 0.590
Dietary Factors:
Na 165
K 55
Mg 79
P 0.772
Nh4 45
Cl 181
Sul 39
UUN 9.65
PCR 1.0
Hi David, You may indeed have left MSK as the stone type and minimal urine abnormalities are just like what I have always seen. Your calcium and sodium are both a bit high and you could do well to lower diet sodium to 1500 mg. But if it is MSK the stones probably form because of stagnant fluid in the cysts. Regards, Fred Coe
Hi Dr. Coe, would welcome your thoughts on the following from Litolink which I received today; I starred the items that are listed as outliers (will have a followup appt with my urologist in another 6 weeks) – Have had stones for about 7 years or so, with the frequency increasing over the past 1-2 years
Volume 3.7
SS CaOx 4.24
Urine Calcium 135
Urine Oxalate 91*
Urine Citrate 829
SS CaP 0.64
pH 6.954*
SS Uric Acid 0.09
Urine Uric Acid 1.177*
Dietary Factors:
Na 150
K 194
Mg 117
P 0.934
Nh4 55
Cl 199
Sul 45
UUN 18.82*
PCR 1.5*
Normalized Values:
Cr24 2995
Cr24/kg 32.2*
Ca24/Kg 1.5
Ca24/cr24 45
Thanks!
Hi Ken, The obvious high oxalate needs attention. Low calcium diet is a common cause. I notice a very high urine potassium but it is not potassium citrate because urine NH4 is higher than sulfate. Do you take potassium chloride or vast amounts of fruits and veggies? These are just thoughts – data alone do not get you very far. Feel free to share them with your urologist. Regards, Fred Coe
Hi Dr. Coe, I have managed to lower my SS CaOx from 17.51 to 5.00, lower my SS UA from 0.49 to 0.02, my Ox 24 from 101 to 29. Calcium and citrate are normal. But my SS CaP rose from 1.61 to 2.47. Also my pH rose from 6.290 to 7.447. I was taking calcium with meals and magnesium citrate. Thank you. Ca 24 is 141 and Mg 24 is 299.
Hi Alice, Perhaps the magnesium citrate is too much of a good thing – or perhaps the calcium is calcium citrate or calcium carbonate. Those will raise urine pH. Can you not use calcium foods at least in part? Otherwise you seem pretty good at changing things. Regards, Fred Coe
As a newbie stone former at nearly 60 and a physician myself I have found your information amazingly helpful. Thankyou.
Hi Dr, Glad you found it so. Fred
Hi Dr. Coe, my nephrologist suggested I visit your website and try reaching out to you as new onset to stones 2 years ago now, 1 year on meds and diet adjust and 24 hr urines still way off normal. diet mostly plant based protein, and un processed foods for last 4 years. fluid intake average 1 gallon a day 90% of which is plain water.
here is last results :
24 HOUR VOLUME 2.42 L/day
PH 6.9
CALCIUM 24 HOUR URINE 577 mg/day
OXALIC ACID 24 HOUR URINE 40 mg/day
URIC ACID 24 HOUR URINE 1,193 mg/day
CITRIC ACID,24 HOUR URINE 2,141 mg/day
SODIUM 24 HOUR URINE 387 mEq/day
SULFATE 39 mmol/day
PHOSPHORUS 24 HOUR 2,047 mg/day
MAGNESIUM 24 HOUR URINE 232 mg/day
AMMONIA 24HOUR URINE 44 mEq/day
POTASSIUM 24 HOUR URINE 117 mEq/day
CREATININE URINE 2,331 mg/day
CALCIUM OXALATE 1.56
BRUSHITE 7.20
SODIUM URATE 6.14
STRUVITE 14.17
URIC ACID 0.30
Hi Kevin, From the numbers, your urine calcium and oxalate are very high, citrate is very high, pH is high, and SS for calcium phosphate remarkable. I presume the urine is not over-collected and that the very high creatinine just reflects high muscle mass. Such massive sodium loading is surely raising your urine calcium, and I would start there – you are over 3 times above the US tolerable upper limit for diet sodium. The plant based diet is giving you lots of potassium and alkali so your urine pH is high which predisposes to calcium phosphate stones. My initial concern would be to get the diet sodium down drastically. It is so high that nothing can be done. If your nephrologist wants more detailed help for you from me, please let me know as that would amount to medical consultation. Regards, Fred Coe
Hello Dr. Coe. My 24-Hour results had only 2 high risk areas: Urine Citrate (335 mg/d) and Urine Phosphorus (0.48 g/d). All the other parameters–including Urine Oxalate (25 mg/d)–were normal or low risk. I’m now increasing my water and potassium citrate intakes. For additional help, should I tend toward eating high- or low-oxalate food groups? Many thanks for your fine web contributions for us stone growers!
Hi Robert, If your urine oxalate is 25 mg/d there is no reason to bother with diet oxalate. The low citrate is marginal making me wonder why you made stones. I wonder if you might have made them at another time in your life when things might have looked a lot different. Drink lots of water and think about the past. Maybe you might get some more clues. I take it your supersaturations, urine calcium etc all are unremarkable. Regards, Fred Coe
Hi Dr Coe,
Thank you so much for all this wonderful information. I am trying to decide if I should repeat my 24 hr urine or not. I ate normally the day I collected it. It was a hot day and I exercised a lot, and therefore drank a lot–more than usual (which I now know is problematic for accurate results!). My stones are calcium oxalate. My 24 hr Ca was 129, Ox 24, Cit 718 and pH 6.077, Na 87. The SSCaOx was 1.63, presumably low bc I drank a lot. Even if I drank a lot, the 24hr Ca, Ox, Cit and pH are absolute values and should be the same regardless, is this correct? If so, there is nothing to change in my current diet and I should be safe if I continue to drink 3L a day. Should I do another urine and eat pizza and spinach salad to see what happens? Should I do another one and just drink 2L (which would be soooo much easier to live with) and see what happens? Thank you so very much for all you do for the kidney stone community:-)
Jill
Hi Jill, Very sharp reasoning. But on hot days we become salt depleted and that can lower urine calcium. Just as a precaution measure again in more temperate weather. As for a lower volume, of course try it. If SS values stay reasonable, perhaps you are done. But why did you form stones in the first place? Were you once unenthusiastic about fluids? Where there other changes. Something caused stones, and now we have all innocence, all normal values. Regards, Fred Coe
Hello again–thanks so much for the reply! I believe you are a treasure of clinical medicine and have likely educated generations of physicians. Thank you!!
I have passed 4 stones from the left in the past year, all with only mild to moderate difficulty. The left is now clear, per the scope I had last month, the only residual is 2 RANDALL’S PLAQUES in the L upper pole (perhaps this is the risk factor for me, even though my 24hr urine is nl).
I agree, the “why did the stones form” question is bothering me as well!!! I have a few theories. In my younger days (I am now in my 50’s, fit and healthy) I did not drink very well at all… I did flirt with the South Beach Diet (low carb high protein) for a while….now I eat 2-3 well rounded meals a day and exercise pretty vigorously 3-4 days a week. I also climbed a big mountain this past summer which required being roped into a team while we traversed multiple glaciers– I seriously dehydrated myself for several days in efforts to not have to pee in the middle of the glacier with all my rope team-mates looking on! I ate a LOT of cashews and almonds on that trip as well….(but the stones on the left were all formed prior to this adventure).
On my right, I have been completely asymptomatic, but when investigating the symptoms of the left it was discovered I had a 2cm mass of many small stones clustered in the R upper pole. My Dr thought maybe caliceal diverticulum, but on fluorscopic dye study the anatomy was normal. So, I have had ESWL x 1, and will have another very soon–hopefully that will be all I need!!! There may be Randall’s Plaques there too, but we don’t know and no scope is currently planned.
My questions are:
Do the Randall’s Plaques mean I have definitely had hypercalciuria at some point?
How long do these stone take to form–have I been working on them for many years?
Maybe I’ll never have another one now that my 24hr urine is normal?
I also wonder (because I love spinach…) do non-stone formers excrete a lot of oxalate after eating spinach? Why do they not form stones? Is there a chance I can still eat spinach, even though my stones were CaOx??
I will take your advice and repeat the24 hr urine study–I’ll probably wait a few months til I’m recovered from the ESWL scheduled for next week. I will drink 2L, not exercise, and eat a normal diet on a temperate day.
Your contributions to this site and to the scientific literature make a difference in many lives. Thanks again for everything!
Jill
Hi Jill, Plaque can form because of dehydration, and once formed offers lodgment to new stone formation. Perhaps your mountains did it, perhaps your genes. Re-study is a good idea, as is hydration. The kidney stone diet is also a good idea as it is healthy – by US standards – and has the traits that would seem to reduce new stones. Regards, Fred Coe
Dr Coe,
In this article it states if Citrate is below 400 to use beverages that provide supplemental Alkali to raise Citrate but would that be accurate also for Calcium Phosphate stone formers since that would raise urine PH even more in already high PH urine? Is it safe to eat a fair amount of fruits and vegs (7-8) a day having a high PH? I see in other articles about using Crystal Light Lemonade for this but doesn’t mention caution with Ca Phosphate stone formers. Do Ca Phosphate stone formers need to worry about increasing their Citrate or best to be mainly concerned with increasing urine volume, lowering urine Calcium by cutting sodium and sugar along with excess protein?
Thank you!
Hi Diane, Whether alkali is good or bad for calcium phosphate stone formers – unanswered because no proper trial. At the moment I try to avoid alkali and work around what is in the urine chemistries as a cause – usually high urine calcium and pH and maybe low citrate. So, reduced diet sodium and sugar, increased volume, and maybe a thiazide – as in the linked article. Regards, Fred Coe
Dr Coe, thank you for answering my previous email and giving me a link to another article. If we are to watch animal protein I find it hard because dairy comes from animal and we need it for the calcium if it’s best not to use supplements. Does the dairy significantly raise an already high urine PH, should a Ca Phosphate former use some supplements rather than all dairy to get the needed calcium so the PH doesn’t rise? Also I have high urine phosphorus of 900 which I’m sure is from dairy, wheat, and bran in the diet, is this a concern for Ca Phosphate formers? I don’t see too much mentioned about urine phosphorus importance in preventing these kind of stones. Thank you!
Hi Diane, Milk comes from animals but has a different protein composition than the animals’ bodies, thus have not even the modest stone risk increase of meat. Milk does not raise urine pH, but may slightly lower it. Phosphate matters but not in the range you note. It is the fraction of the phosphate that has two charged sites where protons were – the acid radical – and that is so controlled by pH the amount of phosphate pales by comparison. So, milk is not a risky way to get calcium. Regards, Fred Coe
Hi Diane, I think I answered this question from another page, but here again just in case. Milk from an animal does not raise stone risk at all, meat from that animal might at high intakes. Urine phosphate reflects intake and has little effect on calcium phosphate stone formation because what matters most is the fraction of the phosphate with 2 negative charges – this is determined by pH. Regards, Fred Coe
Hello Dr Coe.. I am a calcium phosphate former. 24 HR collection showed all levels good except ..low water intake, low citrate 135, high PH 7.634. Low magnesium 21 and 41, High SS CaP 1.7 and 2.95.. Nephrologist says take pottasium citrate.. Urologist says take magnesium citrate. Other outside consultant is concerned that either one of these could raise my already high ph. Why is my citrate so low and ph so high? My health is excellent except for stone forming and I have none of the known risk factors. What to do???
Hi TB, calcium phosphate stone formers are this way, and I suspect it is their heredity. Usually urine ammonia production is higher than it should be and citrate lower, and this arises from a disturbance in the proximal tubules of the kidneys. The link is to our research publication, I have not had time to write it into a site article. You need water enough to raise urine volume above 2.5 liter/d and if there are a lot of stones, thiazide to lower urine calcium, and low diet sodium so the drug will work better. Potassium replacement, if needed, is best as potassium chloride. As for alkaline salts, I agree they may make matters worse. I note the low magnesium, and wonder why – certainly you can replete it with OTC magnesium oxide – not citrate. Regards, Fred Coe
Dr Coe, I eat a lot of good carbs and fruits and just wonder if natural sugars increase urine calcium at all or is it just added sugars that do that? Thank you-
Hi Carol, fruits are usually fine because quantities of sugar are modest. Fruit juices that extract the sugars are as bad as table sugar. It is this way, how many oranges can you eat at a time? One, perhaps. SO the amount of sugar is too low to matter. Fred
Dr. Coe,
How many days does the 24 hour urine results reflect what you have eaten or drank? Is it that day you are doing it, a day or two before, or longer?
Hi Carol, what a great question! For sodium, it is more or less the average of the prior 3 days. For water it is that single collection day. For calcium, it is unknown, and also for oxalate, but probably some kind of several day average. For potassium, phosphate, and magnesium it might well be the day of collection, but I am not sure. See? Lots of research is left to be done. Fred
Hello Dr Coe,
I’m wondering if there is a difference in the type of calcium in the diet that would cause more to spill into the urine. I’m not talking about supplements but between dairy products vs other foods that have calcium like breads, fruits/vegs, etc that isn’t dairy. Thank you-
Hi GF, No. None known. Fred
Dr Coe,
Do Vitamin D supplements alone, not with Calcium added cause increased Calcium in the urine and if so what amount of Vit. D would cause this? If it does cause more Calcium in the urine is it because Vit. D helps the body to absorb more of the Calcium we eat?
Hi Lisa, Just 25D is not known to increase stones. If your 25D is low, I suspect bringing your levels to normal will raise urine calcium, but in the normal range I do not believe urine calcium will much change. Vitamin D is important in calcium absorption, as you say. Regards, Fred Coe
Dr Coe, I can not thank you enough for all your information and hard work. One year ago I changed diet for my Phosphate stones (only one removed in ureter 2019) and was able to change my 24 hr urine tremendously. I’ve had 5 done but am going to give you the results of an early one (2019) then one this week after all those changes. Changes-added sugars between 22-25g, Calcium 800mg (Endo doc said to keep around here), Protein 60g which is from very little animal meat, get from dairy, fruit/vegs, breads and my sodium intake around 1100-1200mg/day plus 15-16 cups of water a day. I have around 9 fruits and vegs a day and realize my citrate is low but believe it comes with CaPhos stone history and what goes along with that. Thankfully with all those fruits/vegs I added my urine PH stays around 7 and does not go higher. The first number being the older and 2nd being this week.
Uro Calcium 324-204
Uro Oxalate 23-29
Uro Uric Acid 513-360
Uro Citrate 350-341
Uro PH 6.9-7
Uro Volume 2.73-4.14
Uro sodium 95-44
Uro Phos 871-584
Uro Mag 87-81
Uro Ox Sat 1.33-.92
Uro Brus Sat 4.39-1.52
Uro Sod Ur Sat .62-.10
Uro Potassium 48-45
Uro Creatine 1054-742
I do know that Calcium needs to be below 200 and Brush Sat below 1 but I think this is all I can do myself. Based on what I read my Creatine is fine because the low range said 600 and I had weight loss from the changes so I’m 49kg and from research I did they go by 15-20mg per kg of body weight. I’m just assuming but I think these changes would be fine without meds “if” I’m not forming new stones or the ones I have are not growing but the problem is they only order Kidney US because they don’t want to do CT’s yearly so it will be hard to tell. Based on US the last couple years I have one stone in each Kidney each between 3-5mm but last CT from 2018 shows multiple scattered stones up to 2.7mm in one kidney. Having new US tomorrow and seeing Urologist next week and I know for certain with the changes he will not want to put me on Thiazide, even when my numbers were high he would say I don’t want the side effects that you can get from them even though I see you’ve written it’s tolerated well. As of now my Endocrinologist says I don’t have PHPT. I had questionable numbers but she asked me to go to a better lab and as said on your website I did the test fasting early morning which wasn’t always done in the past because they said it didn’t matter……I knew better! Each time at new lab and fasting the number were normal. Again I just wanted to thank you for all the info about what to do for my CaPhos stones on your site.
Hi Carol, You are a very capable administrator of your own care, and I am happy for you. I do look with disfavor on the CaP SS over 1, and hope you will lower it more. Urine sodium seems quite low, volume high, so the residual SS is arising from the pH (7) and low citrate. Let’s hope new stone rate falls to 0. I do not like US for stone counting and mention that modern CT scanners can bring the radiation dose to very low levels. Counts are crucial. Regards, Fred Coe
Dr. Coe, I fully agree with you and saw my urologist and he refused me the CT even after I explained that it is low dose and necessary to count. I’m in my 50’s so it’s not like I’m very young for extra radiation. Also he does not believe I need meds because my values are in the normal range for the lab. The range for the PH is 5.5-7 and of course mine is high at 7 and the Brus Sat range is <=2.00 and mine is 1.52. The endocrinologist said she wants to leave it up to the urologist on taking meds. I can not go to another group of endo/uro because I work for this hospital and we have their insurance. Is there anything else I can do on my own that you can think of to lower those numbers? Again thank you so much!
Hi Carol, Frankly I cannot quite figure out how to help you. Perhaps your hospital would let you seek a telehealth consult with me at University of Chicago. It should not be too costly (as a professor I really do not know how billing for my time works). Your physicians might be interested in what I had to say. If you can, my secretary is at 773 702 1475 (Banita Williams). Regards, Fred
Dr. Coe, I’m considering a virtual visit with you as you stated above but seeing if it’s feasible since my insurance will not cover you being fully out of network. They don’t allow a contractual adjustment/allowed amount for out of network services. I spoke with your financial dept about the cost of the visit and it’s over $700. In the meantime while I decide is there any way for me on my own to increase my urine citrate without raising my PH? Again because my physicians believe my numbers are in normal range including my citrate of 341 with the lab range of >= to 320 they won’t put me on thiazides for prevention. Like you mentioned I need to get my Brus SS even lower which I got down to 1.52 from 4.39 as I stated in the original email above to you. I do have urine PH strips I use to monitor and with all the fruits and veggies I added with my changes, 9 a day luckily my PH stays at 7 no matter how many I eat. They will only order a yearly 24 hour urine. I tried on my own to get a nephrologist appt. for prevention but they stated I needed to have a referral from one of my doctors and since my doctors think all my labs are normal I don’t need to go to nephrology. Thanks again for your advice.
Hi Carol, You do have an issue. Your urine citrate is low enough to confer stone risk, and probably reflects more complex problems that cause it. But I do not know how to help. Perhaps there are university physicians who are in your insurance network – I would try that route. Regards, Fred
What do you like the oxalate supersaturation to be? The range on my 24 hour urine states <=2.00, is that what you go for under 2 as a goal? Thanks for your time.
Hi SB, I am not so stringent. The evidence from the main epidemiological studies would place the risk threshold at around 3.3. IN the article you will find the graph of SS for CaOx shows risk increasing above 1, but that is because the graph uses relative SS, the actual supersaturation divided by the mean value from a group of non stone formers. This group mean was 3.3, so on the graph 1 = 3.3. Confusing? Yes. I wish the group had not used relative SS. Regards, Fred Coe