Jeff, a reader of this site, suggested this topic and I realized it was one that I should have written long ago.
You can make sense of all those numbers in the 24 hour kidney stone reports.
You can use those numbers to understand how things stand with you.
Reading the numbers can help you achieve your best possible chance at stone prevention – which is the only reason all those lab tests were done in the first place.
This article deals with calcium stones. A second one will cover uric acid stones.
Be Sure You Have Been Screened For Systemic Diseases
Your physician does this part. But even for systemic diseases stone risk is gauged in the urine so you can read along and assess how prevention is going.
Units of 24 hour Urine Measurements
Time
Because excretions of stone risk factors are in amount per 24 hours, we need the time of the collection. You provide the beginning and end times for the collection, in minutes and hours, and the laboratory corrects all excretion values to amounts in 24 hours.
For example, you start a urine collection at 7 am and complete it at 5 am the next morning. The measured total time is 22 hours. If the volume is 1.5 liters, the volume ‘corrected’ to 24 hours is 1.5 liters x 24 /22 (1.09) or 1.636 liters/24 hours.
It is obvious that the less ‘correcting’ the better, because the ‘correction’ assumes that every hour is the same as every other hour, which is not likely. So you want to collect as close to 24 hours as possible. If your time is below 22 or above 26 hours throw it away – no cost – and do another.
I am sure this is an unnecessary comment but sometimes people forget that a urine collection begins by emptying the bladder, writing down the time, and discarding the urine. Here and there people add it, making the real collection from whenever the bladder had last been emptied.
Volume per 24 Hours
Urine volume is measured in liters (L) or milliliters (ml). A milliliter is 1/1,000 of a liter, so there are 1,000 ml in a liter. One liter is 1.06 quarts. The laboratory measures the total volume of urine if you send or bring it. Often you will read the volume yourself, off of a collection container.
Because excretion rates like calcium, oxalate, citrate, and uric acid are calculated by multiplying their concentrations by the 24 hour volume, mistakes in timing, collection, or measurement of volume will make the results less valid. You provide the collection times, assure all the urine has been collected, and even may measure the volume, so quality is under your control.
Excretion Rates
Urine creatinine, calcium, oxalate, phosphate, and citrate excretions, are in milligrams (mg) or grams (gm) per 24 hours. A mg is 1/1,000 of a gram. An ounce contains 28.3 gm.
Urine sodium is measured in millimoles (mmol) or milliequivalents (mEq)/24 hours. Atoms, like sodium, each have a weight made up mainly of their constituent protons and neutrons. One mmol of sodium is 23 mg.
Some atoms like calcium have two charged sites which can bind to other molecules or atoms. They are often measured in milliequivalents (mEq) which is the weight times the number of sites. Sodium has only one, so mmol and mEq are the same.
Molecules like creatinine and oxalate have weights made up of their constituent atoms.
Conversion of Units
Some laboratories report in mmol or mEq. You can convert your lab report if it differs from mine. I will be using L for urine volume, mg for urine creatinine, calcium, oxalate, and citrate, and mmol for urine sodium. Here are the conversions:
Creatinine; 113 mg/mmol
Calcium: 40 mg/mmol; 20 mg/mEq
Sodium: 23 mg/mmol or mEq
Oxalate (oxalic acid): 88 mg/mmol; 44 mg/mEq
Citrate (citric acid): 189 mg/mmol
Direct Measurements
Acidity or alkalinity are measured in pH – no units. It is a logarithm to the base 10 so a change from 6 to 5 means a 10 fold increase in acidity, from 6 to 7 a ten fold increase in alkalinity.
Supersaturations are calculated from urine concentrations. The one we use here is the ratio of the concentration dissolved in urine of each of the three important stone forming salts, calcium oxalate, calcium phosphate, and uric acid divided by their individual solubilities at body temperature. Values below 1 mean crystals will dissolve. Values at one mean crystals will neither grow nor shrink nor form. Values above 1 mean crystals can form and grow. Being a ratio it has no units.
Is The 24 Hour Urine Valid?
Urine creatinine
Like all 24 hour excretion rates, that for creatinine is calculated from the concentration, measured volume, and collection time.
Because muscle cells make almost all the creatinine lost in urine any two urines you collect will have about the same amount of creatinine in them. A more than 20% variation between two urines suggests an error in one collection. If there are many collections, most creatinine excretions will line up pretty well, and an outlier – too high or low by more than 20% of the average for all the collections will stand out.
When a urine stands out as different from prior collections, I say it is best to repeat it. If there are two, use the one that seems more correct.
‘More correct’ is judged by expected amounts of urine creatinine. For men, one expects about 18 – 24 mg/kg body weight; for women, 16 – 22. A urine far out of those ranges is suspect. In people who have a high body fat percentage the ratio can be as low as 12 mg/kg/day, and people who have little body fat and a high muscle mass can be as high as 30 mg/kg/day.
Conditions of Collection
Did you eat and drink as usual, or show off? Had you ‘improved things’ since a recent stone so your collections reflect new habits and not those that led to the stones? Every collection is a one day frame out of a movie that is running 365 frames a year, so if these few days do not reliably represent your average life, their results will inevitably mislead you and your physicians and falsify what you came to do.
Reading the Results
Urine Volume
Curhan and colleagues have linked new onset of stones to urine volume in three large cohorts reviewed in our other articles. Take a look now. The graph is on page 2 of the article. Risk is on the vertical axis, and urine volume is on the horizontal axis. When red shows above the line at 1 it is above normal.
Risk is low above 2.25 liters/24 hours. But the day is long and the 24 hour urine is an average, so for insurance it is best to overshoot so the low times are still not too low. I would say 2.5 – 3 liters liters/24 hours is ideal.
Urine Calcium
Stone risk increases with urine calcium excretion above 200 mg/day in men and women – take a look. The calcium risk is at the upper left corner of the graph.
If you have above 200 mg/24 hours you have ‘hypercalciuria’, a high enough calcium to pose risk of stones – and also bone disease. There are many causes of hypercalciuria. The commonest is simply a genetic tendency, called idiopathic hypercalciuria. ‘Idiopathic’ means your physician has ruled out any of the other causes of hypercalciuria.
You lower urine calcium in idiopathic hypercalciuria with reduced diet sodium, avoidance of sugar loads, and medications if needed. You compare treated to untreated excretion to see how well the treatment worked.
Urine Sodium
Urine sodium is essentially the diet sodium intake. Because urine losses can lag intake when intake varies sharply, urine sodium is a good estimate of the average over 3 – 4 days. If you tried to lower your diet sodium to 100 mmol/24 hours, 2,300 mg intake, and you find 200 mmol/24 hours, you can be sure that your average intake is on average twice what you desired.
Suppose your urine calcium is 250 mg/24 hours, urine sodium 200 mmol/24 hours – twice the upper limit of diet sodium in the US and above the optimal value of 65 mmol (about 1,500 mg/24 hours). You would want to lower your diet sodium. Suppose your urine sodium was already 65 mmol/24 hours and urine calcium was 250 mg/24 hours; you would want to take other steps like thiazide diuretics or potassium citrate.
What if your urine calcium is 450 mg and your urine sodium is 200 mmol? Sounds like a bigger problem, but it is not. When urine calcium is higher the slope dependency of urine calcium on urine sodium is steeper, so the same reduction of sodium could bring urine calcium quite a way down.
If you lowered diet sodium and there is no change, do not assume the test is wrong. Check the creatinine values – do they match? If so, you have not lowered your average sodium intake. Sodium is an atom and you are not a cyclotron; you cannot make sodium or destroy it.
Sugar Loads
Given to people with idiopathic hypercalciuria they cause a rapid rise in urine calcium and supersaturation. The 24 hour urine will tend to underestimate this because of averaging throughout the day.
Thiazide Diuretics and Potassium Citrate
These drugs come after diet changes have not proven sufficient and are added to the diet changes.
Urine Oxalate
Stone risk increases with increasing urine oxalate and if the risk ratio is not as high as for calcium risk appears at very low levels of excretion – above 25 mg/day. In general, high urine oxalate comes from high oxalate diets, low calcium diets, or the combination of high oxalate and low calcium together. Therefore treatment is dietary. Excellent food lists are in this site – linked from the oxalate diet article. Rarely, urine oxalate is raised from a hereditary overproduction state – primary hyperoxaluria. Likewise, bowel diseases can raise urine oxalate. These are complex conditions and diet alone is rarely enough.
If urine oxalate is high and you have corrected both your diet oxalate intake and added significant diet calcium, you may have some form of genetic or acquired oxalate overproduction or an otherwise inapparent intestinal absorption problem.
Urine Citrate
Citrate is a powerful force against calcium stones. It binds calcium in a soluble complex. It interferes with calcium crystal formation and growth. Low urine citrate is a risk factor for new stone onset – bottom left panel of the graph. Above 400 mg daily there is no extra risk of stones in men or women, so ‘hypocitraturia’ means a urine citrate below 400 mg daily.
If you begin taking, as an example, four 10 mEq potassium citrate pills a day – 40 mEq, that extra 40 mEq of potassium should appear in the urine. If it is not there, the pills may not be delivering the medication into the blood from the bowel. The urine pH should rise because citrate imposes an alkali load. If it does not and the urine potassium does rise, you may need more of the medication.
Urine ammonia – I will cover this in the second half of this two part article – is a major way the body removes acid, so when you take citrate ammonia excretion should fall. If it does not fall, and urine potassium rises perhaps your pills are potassium chloride – the pharmacist switched from what was prescribed.
Strangely, the urine citrate itself does not rise in everyone even when potassium and pH rise and ammonia falls.
Urine pH
A low value – below 5.5 poses a risk of uric acid stones. A high value, above 6.2 raises calcium phosphate supersaturation and risk of calcium phosphate stones. Potassium citrate can raise urine pH; there are no medications to lower urine pH except methionine and ammonium chloride and these are not usable for stone prevention because they will increase urine calcium and pose a risk of bone mineral loss.
Urine Supersaturations
Get Them
If there are no supersaturations, ask that your samples be processed by a vendor that provides them. Supersaturation is the driving force for crystal formation and growth, and invaluable for monitoring stone prevention.
Relate Them To Your Stone Crystals
There will be three supersaturations: Calcium oxalate, calcium phosphate, and uric acid. Inspect the ones related to your stone crystals. For calcium oxalate both calcium oxalate and calcium phosphate supersaturations matter. If calcium phosphate, that one matters most. If pure uric acid, it is uric acid supersaturation.
Reduce Them
One should not compare values in a stone former to values in normal people, who often have urine supersaturations as high or higher than those of stone formers. Active stone formation means supersaturation is too high for you whatever the value may be and needs to be lower. You reduce your supersaturations by increasing urine volume and reducing excretions of calcium and oxalate, or raising excretion of citrate without undue increase of urine pH. That is why we make these measurements.
Compare Then to Now
Compare you now to you before your most recent fluid and diet intakes or medications: If they have fallen, things are going well; if they have risen things are not going well. If stones are still forming, supersaturations need to be lower. If there have been no more stones and supersaturations are stable, stand pat. If supersaturations are below 1 and stones are still forming, the urine samples do not properly represent your real life.
A Good Schedule
When? I like two 24 hour urines before treatment – it gives a sense of averages. After treatment has begun – diet changes, fluid goals, lifestyle, it is important to get another. The timing is up to patients: You know when something has changed, or ought to have changed, and need to be sure it has indeed changed in the right direction. It goes on like that until treatment is reaching its goals – lowering supersaturation by at least half – after which once a year is a good idea.
Hello! Can you help me understand the ratio you talk about for the supersaturations of calcium oxalate, calcium phosphate and uric acid? You mention what happens to crystals <1, at 1, and above 1 . . . however, the ratios I see listed on the metabolic report have ranges of 6-10 for CaOx and 0.5-2.0 for Ca Phosphate. Is there something further that needs to be done for this number to get the ratio? Thank you!
Hi Natasha, the numbers you quote are the supersaturation ratios. For example supersaturation for calcium oxalate (CaOx) commonly ranges from 6 to 19 fold, meaning 6 – 10 fold above saturation (at 1). So they are ratios and represent the final stone risk measure. The normal ranges are not really important here. WHat matters is this; If you are actively forming stones, your supersaturation is too high in relation to the crystals in those stones. For example if you are forming CaOx stones, and your supersaturation ratio is 7, that is too high for you and needs to be lowered. But, it is up to you to be sure the collections from which that SS is derived represent your life as lived – your real average life, not simply weekends or other potentially special times. Forming new stones means passage or appearance of stones by CT or ultrasound not already present in the past on prior CT or ultrasound studies. Regards, Fred Coe
Hi, if the normal range of supersaturation for CaOx is for example 6-10, does it mean that almost all of us are constantly forming CaOx crystals ? And if that is the case, what makes the difference between who actually form stones and who just form crystals but never forms stones?
Hi Ken, A great question and thank you. Metastable supersaturation means that a solution can be supersaturated and yet form no solid phase. Urine is metastably supersaturated. The upper limit of metastability is higher than the supersaturation. When the upper limit is exceeded, by definition, crystals form. For CaOx the ULM actually rises with the SS, and is often above it by a large margin. For Calcium phosphate, it is very close to the SS so the SS itself is rarely above 2 – 4. For CaP citrate and perhaps inorganic pyrophosphate seem to create the inhibition of crystal formation needed to maintain the ULM – that is an open research question. For CaOx I have no idea – no one does – what the inhibitory molecules are. Stone formers are unlucky – they make crystals and stones at values of SS normal people easily tolerate. Regards, Fred Coe
Hi Dr. Coe,
My calcium ur is 399 mg/24hrs.
Oxalate ur is 38mg.,Utica acid ur is 785mg/24 hrs.,citrate ur is 453mg/24hrs., ph ur is 6.9 and brush its is 3.83.
Can you tell me how shall I deal with that. Thank you so much.
Jean
Hi Jean, Your urine calcium is high. Here is an article on this topic. Your physician has to figure out the cause.Treatment is then straightforward. Your urine is rather alkaline, so perhaps you are a calcium phosphate stone former. Regards, Fred Coe
Thank you so much, Dr. Coe.
Calcium Ur 616mg/day, Oxalate Ur 115mg/day, Uric Acid 1584mg/day, sodium Ur 513mEq/day, sulfate Ur 39mmol/day, Phosphorous Ur 2607mg/day, Ammonium Ur 85mEq/day, Creatinine Ur 4247mg/day, Calcium Oxalate 3.08, Brushite 4.20, Sodium Urate 5.67…..results of a 24 hr urine study 9 days after passing kidney stone. Doctor not very concerned, but not sure if I should be because these are all very high….Opinion?? I do have a history of Calcium kidney stones and off the charts low bone density….
Hi Annette, These data include a urine creatinine of 4247 mg/day, an impossible amount. Given your female name and the general size of women’s muscle mass, I would judge it is off by about 3 – 4 fold. So the calcium of 616 mg is really more like 250 or 200 mg. My immediate suggestion is to call your physician and or the lab and let them know about this problem. Perhaps they can identify the reason for the error – for error it is – and correct matters. Feel free to use this note. No medical decisions should be made using this kind of mistaken information. Regards, Fred Coe
yes, that is what the results said, also the total Urine volume was 3.30 L/day and PH Urine was 6.5 , and I questioned the doctor’s office twice since they were so high, and they were not concerned and said see you in May for your appointment to go over the results… not sure I shouldn’t worry.
Hi Annette, Even though I know nothing more than what you sent, that creatinine is high by threefold or more so I do not trust the lab. I would repeat the study with a reliable national kidney stone laboratory. The data are unusable in their present form and of that I am certain without reservation. This is not a medical opinion about you but merely a technical appraisal of the lab data. Regards, Fred Coe
I passed a kidney stone in February after which an ultrasound showed that I had several largish sized stones in my left kidney. The urologist ordered a 24-hour urine test. Every single result was well within normal parameters except that I was just shy of 2L total urine volume (1.99L). Before the kidney stone I had been taking a multi-vitamin with 500 mg of calcium, but I had stopped that before the urine test because the doctor’s office said it could contribute to stone forming. I was also drinking a lot more water at the time of my 24-hr test than I had been before. If they had done a 24-hr test before I made those changes, I’m sure it would have been much different. Because of the number and size of the stones in my left kidney, the doctor ordered a ureteroscopy and laser lithotripsy which I had done last week. I never, ever want to have to go through that again, but the feeling I get from the doctor’s office is that they view it as inevitable. “Some people are just stone formers”, they say, and it does run strongly in my mother’s family. But is it possible that with a completely normal 24-hr urine sample that I am destined to make more stones? I wish the doctor’s office had told me not to make any changes until after they had got a 24-hr test because then I would be able to see the difference that resulted from the changes I made. In your opinion could the combination of the calcium in the supplement and the much lower volume of water that I was drinking have caused my problems considering the fact that my 24-hr test came back so normal after I fixed those 2 issues? The doctor’s office is pretty much telling me to reconcile myself to the fact that I am destined to have more stones, which really bothers me. There is so much information on your site that I am literally overwhelmed at times…in a good way! I’m trying to take it all in, but after reading this article about the 24-hr urine test and seeing that all of my results were normal I’m at a loss of what to think about my situation.
Hi Dawn, Your comments make remarkable sense. Your doctors were neither right or wrong. They wanted to see you as you are, but in fact with a lot less fluid and more calcium you may well have looked more abnormal. I notice you used my article – so your calcium would have been below 200 mg, oxalate below 25 mg, citrate above 400 mg – you gave the volume. As for inevitability, that is not true. If you have really brought everything to normal, and can keep things the way they were then you did your test, you may make no more stones. I would recheck in a month or two to be sure things remain normal. Even one more stones and you can just push things more below normal. Here is a good source for you. Also, be sure you have been fully evaluated. Regards, Fred Coe
The only number that wasn’t below your recommendations was the oxalate. That was 30. The lab considered anything under 45 normal, but I see now my number needs to 25 or below. My citrate was 691, which may have been partially due to the lemon water I had been drinking after passing that first stone. I am seriously applying what I’ve read about diet and fluid–drinking close to a gallon a day and being careful to consume enough calcium from food as well as being sure to eat calcium foods with oxalate foods at meals. Hopefully this will help bring that oxalate number down. I cannot tell you how thankful I am for the information you have on here. I’m thankful for my doctor, but as you mentioned in another article, he is a busy man and I have had so many questions that it would have taken far longer for him to answer them all than could be done in the office. The information on your site has given me hope and direction. THANK YOU!
Hi Dawn, I guess I would recheck after a while to be sure you have corrected everything, as I said. Regards, Fred Coe
Hi Dr. Coe,
You say above “When urine calcium is higher the slope dependency of urine calcium on urine sodium is steeper”
Where can I see that actual graph – urine calcium vs urine sodium?
Maybe it is unique to each individual, but maybe an average graph for the 95th percentile exists?
Even if you can provide a link to a reference, that would help.
Thanks
Jason
Hi, It is multiple places. Here is one. Look down to figure 2 or so and there will be the graph you want. Each point is from either a trial or observation. I brought together every report I could find to make the figure. Fred
Hi Dr. Coe,
I’ve been having a lot of pain in my lower left abdomen for about 5 years. Three years ago, I visited a urologist who found a 11mm stone in the bottom lobe of my left kidney. After SWL, a Steinstrasse, hospitalization and stents, in the end I still had the stone, but now it’s in the renal pelvis. The pain is still there. The stone is CaOX and I think also phosphate. Lately, I’ve been getting painful episodes, which are always followed by blood-clots (up to an inch in length). Half the time, my urine is very cloudy like a snowglobe. I’ve been drinking 3/4 gallon of water a day for a few years now, but it doesn’t look like the stone is getting smaller. I had a cat-scan for my bowels the other day and the stone is now 10mm by 15mm. Would it help if I started to take large amounts of citric acid? I’ve been trying lemon juice and apple cider vinegar (after the cat-scan), but I’m not sure if that helped.
This website is very helpful, I’ve learned a lot about how and why kidney stone.
Also, can you recommend an expert in NYC?
Thank you,
JFJ
Hi, I think that you need a real evaluation, and here is a really nice source. Please don’t just reach for something, find out what is causing the stones and correct that. Let me know, Regards, Fred Coe
Hi Dr. Coe,
Can you please tell me if there is something you can share from your experience about the ballpark range of how much, for example, a 300 mg increase or decrease in dietary Ca would be expected to raise or lower Ca 24 excreted?
For the purpose of discussion, let’s assume a patient with typical IH that is on a low salt, moderate protein, sugar, and oxalate diet with 1000 mg Ca daily (from diet, esp. dairy).
I’m seeing a bigger number than I expected and I’m trying to understand it. Grateful for any help you can offer! -Al
Hi Al, If diet sodium – 24 hour urine sodium – is low, diet calcium affects urine calcium very little as bone takes up some that is absorbed. By low I mean sodium of 65 mEq/day. Higher sodium means a higher response to diet. But people do differ. My suggestion is to stay at 1000 mg calcium and lower sodium enough to bring the calcium down. Lowering diet calcium is the worst way. Regards, Fred Coe
Hi Dr. Coe,
Thank you very much for your help. Very interesting. Say sodium is ~65 mEq, normal Ca intake is 1000 mg, and adding an extra cup of milk raises Ca 24 by around 60 mg.
Would it be a reasonable hypothesis that perhaps the bone is not taking up Ca normally as you explained in your reply, and it may be prudent to check for bone loss?
Best regards, Al
Hi Al, I never can predict to such a cipher. In general at 65 mEq a day most people can take in 1000 mg without too high a urine calcium. If that is not possible I use thiazide with the low sodium high calcium diet. Fred
Is the SS CaOx the serum calcium level? I’ve been told that because mine is high (10.69), this could be indicative of problems with my parathyroid.
Hi Mary Ann, Hyperparathyroidism is diagnosed from a high serum calcium. Here is a good article to introduce the topic. Here is a longer one if you have the stamina. Urine supersaturation per se does not give a clue to primary hyperparathyroidism – it begins in the blood. Regards, Fred Coe
My doctor ordered two 24-hour urine collection tests for me after I had kidney stones (one incident). But I have no idea how to read the results, if I need to change my diet, and so on. Unfortunately, I changed my diet before giving these urine samples (more water, eliminated nuts, dark leafy greens, etc.), so I don’t know what my “normal” results would be.
Here are some of my results (mine come first, then the “standard range”) — could you help me interpret them? thank you so much!!:
First day:
CITRIC ACID PER VOLUME (U) 695.00 mg/L mg/L
CITRIC ACID 24HR (U) 904 mg/d 320 – 1240 mg/d
CITRIC ACID/CREAT RATIO (U) 1121 mg/g >=150 mg/g
OXALATE PER DAY (U) 18.00 mg/d 13 – 40 mg/d
REFERENCE INTERVAL: Oxalate, Urine – mg/day
Access complete set of age- and/or gender-specific reference
intervals for this test in the ARUP Laboratory Test Directory
(aruplab.com).
OXALATE PER VOLUME (U) 14.00 mg/L mg/L
CREATININE PER VOLUME (U) 62 mg/dL mg/dL
CREATININE 24HR (U) 806 mg/d 500 – 1400 mg/d
Performed by ARUP Laboratories,
COLLECTION LENGTH 24 hr hr
TOTAL VOLUME 1300 mL mL
CALCIUM, MG/DL, UR 12.0 mg/dL 0.0 – 250.0 mg/dL
CALCIUM/GM CREATININE, 24 HR 156 mg/g creat mg/g creat
URINE VOLUME 1300 mL 600 – 1600 mL
CALCIUM EXCRETION, UR 156 mg/24hr 100 – 300 mg/24hr
CREATININE 24HR (U) 77 mg/dL mg/dL
CREATININE EXCRETION, UR 1002 mg/24hr 600 – 1800 mg/24hr
Second day (these are all the results I’ve been sent so far):
URIC ACID, 24 HR 465 mg/24 h 65 – 630 mg/24 h
URIC ACID/CREATININE RATIO, 24 HR 476 mg/g creat 90 – 660 mg/g creat
CREATININE 24HR (U) 0.98 g/24 h 0.63 – 2.50 g/24 h
URINE VOLUME 1500 mL mL
Hi Leslie, The urine studies are not as complete as I would have hoped but I can say the volumes 1,300 and 1,500 ml are way too low. The ideal is above 2.25 liters. In the first urine the calcium is high per unit of creatinine but within the risk limits. Oxalate likewise – in fact it is so low I suspect the quality of the assay. So from these the message is more fluids. But on a higher level, you need to be sure your whole evaluation has been sufficient. Here is a good guide. If you have no systemic disease causing stones – your physician needs to assure that – and diet is the way, here is a good diet approach. Regards, Fred Coe
Dr. Coe – I received my results from the 24-hour urine sample and by urine pH is 6.634. Everything else seems to be in the normal range. I am not sure how to adjust my diet to lower my risk of stones. Could you help?
My other results:
Urine volume – 2.49
SS CaOx – 3.37
Urine Calcium – 125
Urine Oxalate – 29
Urine Citrate – 712
SS CaP – .76
24 hour urine pH – 6.634
SS Uric Acid – .08
Urine Uric Acid .371
Thanks, Dr. Coe. I sure appreciate your guidance.
Kate
Hi Kate, I wonder if things have changed since you formed stones so that whatever increased your risks is gone. right now there is nothing to do, so far as I can see. But I am looking at mere numbers and your physician knows your whole story and surely can see more into the problem. Regards, Fred Coe
Thanks, Dr. Coe. I always appreciate and value your good guidance for all of us.
Hi Dr. Coe,
I just received my Litholink results back and everything was in normal range with the exception of Citrate at 191 and pH at 7.092. I have been on 50-100mg of Topomax for close to 10 years for migraines, and after doing my research saw that this can lead to the low citrate levels. My uro just put me on 30 mEq of potassium citrate and I’m going to stop the Topomax. My concern now is getting the pH level fixed. Do you believe stopping the Topomax and getting the citrate level back up to normal will help the pH level, or should we be looking for a different reason that could be causing the higher pH level? Thank you for your help!
Hi Lisa, this drug causes high urine pH and low citrate by its very chemical nature. If you have no stones, I am not sure why testing was done. But if you are concerned stones may form it is best to change to another drug. The urine citrate will not rise much with k citrate so long as you take the drug, but should rise when you stop it. Regards, Fred Coe
Hi Dr. Coe, Thank you for your response. I have had stones for about 10 years now and generally pass 1 or 2 per year. I stopped the Topomax the day I wrote the post to you and have been off of it for 2 weeks now. My uro had me stop the K pills as well to see if the Topomax was the issue and I am repeating my Litholink test in a couple of days (2 weeks post stopping medicine). So my question is two fold:
1. Should stopping my Topomax without taking the K pills be enough to raise he citrate level alone or would I be better off taking the K pills after stopping the medication in order to help raise the level?
2. Would taking the K pills help dissolve the stones that I do have so I wouldn’t have to worry about them? My stones are always Ca stones?
Thanks!
Hi Lisa, The Topamax causes renal tubular acidosis. That disease effect raises urine pH so calcium phosphate stones form. Potassium is always lost in the urine for complex reasons – yes, an article on RTA is long overdue. So you will be potassium depleted. Most potassium is in the cells, so even when your serum level is normal kidney cells may continue to take up citrate leaving little for the urine. The potassium you need is potassium chloride; the citrate is counterproductive right now. No, the stones – usually calcium phosphate – will not dissolve, unfortunately. As well you may have other causes of stones, so the followup study is very important. Regards, Fred Coe
Hi Lisa, The Topamax causes renal tubular acidosis. That disease effect raises urine pH so calcium phosphate stones form. Potassium is always lost in the urine for complex reasons – yes, an article on RTA is long overdue. So you will be potassium depleted. Most potassium is in the cells, so even when your serum level is normal kidney cells may continue to take up citrate leaving little for the urine. The potassium you need is potassium chloride; the citrate is counterproductive right now. No, the stones – usually calcium phosphate – will not dissolve, unfortunately. As well you may have other causes of stones, so the followup study is very important. Regards, Fred Coe
Dr Coe,
I’m having trouble relating my results.
Stone Risk Analysis
Ca Oxalate 2.65 (<2.00)
Brushite 6.4 (<2.00)
Sod Urate 5.83 (<2.00)
Urinalysis
PH 7.0
Protein 100ml/dl
Blood trace-lysed
Stage 2 CKD, labile hypertension and sinus tachycardia. Could these be caused by the stones or vise versa? Also very high renin and aldosterone.
Hi Stacy, I guess there are not a lot of numbers here for me to look at. Stone formers have an increased risk of kidney disease and hypertension, so your high blood pressure is not a surprise. The very high CaP supersaturation – Brushite 6.4 – suggests a high urine pH and perhaps high urine calcium, but there are no values. If you would share more, I could try to help more. Regards, Fred Coe
Thanks for responding, Dr!
All of the other results were normal.
Sodium- 152
Sulfite- 11
Phosphorus- 649
Magnesium- 69
Ca Oxilate- 2.65
Brushite- 6.40
Sos Urate- 5.83
Struvite- 13.38
Utica A Sat- 0.21
Ammonium- 16
Potassium-28
Creatinine- 1279
PH- 7.0
Renin- 25.8 (range 0.5- 4)
Aldosterone- 48.2 (range 5-30)
Ultrasound of Kidneys:
Right- 9.7 * 3.6 * 5.5cm, several small central callus cases may be vascular small kidney stones.
Left- 9.4 * 5.2 * 4.9cm, mildly dilated central renal collection system.
Abdominal CT w/o Contrast:
Small scattered bilateral nephrolithiasis is identified up
to 2 mm in size. These are more numerous on the left. Mildly
pronounced extra renal pelvis of the left is noted without
caliectasis. Both ureters are difficult to follow however no
definite ureter calcifications are identified. Right pelvic
calcification image #80 is present felt to be medial to the
expected region of the right ureter. Mild/moderate
prominence is suggested of the uterus. Small dependent fluid
in the pelvis.
First large stone passed at age 14, about one or two per year since, although not nearly as painful as the first few. Had severe left flank pain for 3 years from ages 20-23 but doctors dismissed as drug seeking. Still have mild to moderate intermittent bilateral flank pain.
Six years ago at age 26 while pregnant, developed severe labile hypertension and sinus tachycardia. It has worsened over the years.
Wondering (getting desperate) if possible nutcracker syndrome of an accessory left inferior pole renal artery would show on arteriogram? My symptoms are orthostatic typically. But I suppose that would not explain the kidney stones on the right side..
I appreciate your help so much, Dr! Thank you!
Hi Stacy, This is very complicated but your brushite SS is high! and your urine very alkaline – pH 7. I put my main questions there. Why so alkaline a urine? Urine sodium is very high, potassium very low, you have almost no urine sulfate – low protein intake – your urine ammonia exceeds your sulfate, all of which points to possible potassium depletion. The high renin and also suggest that despite the high urine sodium you are stimulating these hormones that usually rise with body volume depletion. Do you take diuretics? Have you been vomiting? Your physicians need to make sense out of these measurements. I cannot do much more from here. But perhaps if you mention these comments to them they will know why. Regards, Fred Coe
Thank you Dr!
The urologist that ran the test recommended I drink lemon water and wasn’t concerned since the stones weren’t large. I’ll take this info to my next nephrology appt and hope he has an idea. Would you recommend potassium supplement and an increase of salt? Maybe Gatorade? My only medications are Losartan for BP, Corlanor for sinus tachycardia, and occasionally Clonidine for hypertensive crisis, but I try to avoid as it seems to cause a rebound spike and makes me feel pretty gross. When I was prescribed a diuretic a few years ago for BP, it made my palpitations very severe and I fainted at work. If you are accepting new patients, I could travel to see you and pay cash. Or if you might be able to recommend certain tests I can request? I feel like all of my symptoms are related and I’m just not able to put my finger on a cause or treatment. Thank you so much!!
Hi Stacy, Lemon water is a bit silly, isn’t it? You already have an alkaline urine and high brushite supersaturation. As for sodium you already have a lot in your diet and therefore in your urine. It sounds like you have rather severe hypertension as well, given use of Clonidine. Your nephrologist sounds like a more promising person to figure out what to do. If you are indeed potassium deficient it would be potassium chloride to take – not the citrate. But the alkaline urine pH is an issue for him/her to figure out. I could always see you if your physicians felt it was important, but usually personal physicians can take care of things. Regards, Fred Coe
Thank, Dr.
I wonder about the high urine sodium.. As I do not eat a high salt diet, although not technically low sodium either. The DASH diet made my symptoms worse for no good reason! Also, my blood sodium levels tend to run a little low, either the bottom side of normal or even slightly under normal.
Hi Stacy, Sodium in your urine is sodium you ate. A good goal is 1500 mg/d. Blood sodium will not fall in a normal person eating such a diet unless she is taking a diuretic drug, or has been vomiting or has diarrhea. Regards, Fred Coe
I am 40 years old and have had kidney stones since I was 16. They have increased in size dramatically lately & are occurring more frequently. I recently had a 24 urinalysis & am wondering if you could help me understand the results more clearly. I am just going to give you what I have, sorry if it is way too much info.
CA Oxalate Crystal 0.89 DG
Brushite Crystal -1.09
Hydroxyapatite Crystal 5.19 DG
Uric Acid Crystal -4.73
Sodium Urate -1.52
Length of Collection, 24 Hr UR 24 h
Volume, 24 HR UR 4000mL
Interpretation
The DG is related to supersaturation. DG is negative for undersaturated solutions, zero for solutions at the solubility product, and positive for saturated solutions. Any value greater than the Reference Mean is considered a risk for the respective crystal type formation.
Sodium 56 mmol/24 h
Potassium 24 mmol/24 h
Calcium 280 mg/24 h
Magnesium 160 mg/24 h
Chloride 44 mmol/24 h
Phosphorus 160 mg/24 h
Sulfate 12 mmol/24 h
Citric Acid 84 mg/24 h
Oxalate 0.20 mmol/24 h
Oxalate 17.6 mg/24 h
Ph, Urine 6.7
Uric Acid 640 mg/24 h
Creatinine 920 mg/24h
Osmolality 112mOsm/kg
Ammomnia 20mmol/24 h
Urea nitrogen 6.7 g/24 h
Protein Catabolic Rate 67 g/24 h
I also had a PTH Intact Test, those results were 16.0 pg/mL
Like I said, I hope I am not giving you way too much information or presenting it in the incorrect way. I was told that I have a severe citrate deficiency. If you would please let me know what your thoughts are I would really appreciate it!
Thanks so much!
Hi Liz, Your urine volume is high, sodium low, calcium hefty – I am sure you have genetic hypercalciuria, and pH is high. Do you form calcium oxalate or calcium phosphate stones? Of interest your urine potassium is very low and your urine ammonia exceeds sulfate as occurs with potassium depletion. Your citrate is indeed low, but potassium depletion does that. Have you had vomiting, diarrhea, or diuretics that lowered your potassium stores? Is your serum potassium perhaps low, or serum bicarbonate? Given the present picture of slight supersaturations, low citrate, and lots of stones, perhaps a diuretic – to lower urine calcium further – would be ideal along with potassium citrate. Even potassium chloride might help and not increase urine pH further. Ask your physician what he/she thinks. I like chlorthalidone, 12.5 mg daily. Regards, Fred Coe
Hi Dr. Cole,
I received my 24 hour urine results and need help interpreting results please. There is a lot to consider. Thank you!
Day 1 Day 2
Vol 1.56 1.56
SS CaOx 9.90 10.13
Ca 240 242
Ox 44 45
Cit 943 785
SS CaP 2.96 3.56
pH 6.891 6.852
SS UA 0.13 0.15
UA 0.689 0.715
Dietary:
Na 177 143
K 83 88
Mg 112 109
P 0.743 0.923
Nh4 19 25
CI 174 140
Sul 35 38
UUN 8.15 8.51
PCR 1.1 1.1
Normalized Values:
Cr 1420 1530
Cr 24/kg 25.7 27.6
Ca 24/kg 4.3 4.4
Ca 24/Cr 24 169 158
Hi Pam, Here is what I can do: Tell you technically what the numbers tell me. But for your care you need your physician to be in charge and take responsibility. Your urine volume is low, calcium is high, oxalate is high – usually the latter is low calcium diet. Your urine is alkaline and supersaturated with calcium phosphate and oxalate so you have considerable stone risk. Your sodium intake is high and that will raise your urine calcium. I wonder if you take potassium alkali as your urine MH4 is low, but perhaps you eat a lot of fruits and veggies. You are low in body fat, something rather prized these days. Speak to your physician about higher diet calcium for the oxalate and much less diet sodium – 1500 mg is ideal – for the urine calcium. Your citrate and pH are so high that potassium citrate are not advisable. But do not do these things without his/her review and analysis. Regards, Fred Coe
Hi Dr. Coe, I am in the middle of taking Jill’s course and it has been helpful. I had lithotripsy in 2009 that resulted in me ending up in ICU followed by the need for a cardiac ablation. CT in 2012 showed 15+ stones, current sonogram show about 3 (6mm). My question for you: I had (1) 24 hr urine in 2012 and (3) 24 hr urines this year. They are all over the place and have little consistency. It is VERY frustrating knowing how to proceed and sadly I have not had good experience with finding the right guidance. In the beginning of the year I was put on blood pressure medicine and feel that has been the cause of the varying results this year. Is that possible? For 1 month I was on a diuretic (indapamide) and the numbers on the 24 hr urine went bonkers so I was then switched to Norvasc and they changed again. Any feedback would be greatly appreciated!! My greatest thank you!!!
VOL SSCaOX Ca24 Ox24 Cit 24 SS CaP pH SSUA UA24
10/31/17 3.63 2.26 206 25 429 .24 5.827 .62 .790
9/26/17 4.15 1.01 74 26 273 .13 6.266 .17 .567
5/02/17 2.63 2.83 91 37 711 .20 6.044 .46 .630
7/23/17 1.79 6.67 167 38 600 .82 6.106 .56 .615
Hi Christa, It would appear that you raised your urine volumes, perhaps raised your diet calcium, as time went on. I do not see much chaos. YOur present stone risk looks rather modest. But in all fairness, this is not a medical opinion, merely a brief note about the measurements. In the latent 24 hour urine calcium is just at the risk threshold, oxalate creates no risk, but urine citrate is a bit low. Perhaps the diuretic caused some potassium loss. I see 4 studies in 2017 and none in 2012, by the way. Are you sure you are still forming more stones? YOur chemistries are not very worrisome. Regards, Fred Coe
Hi Dr. Coe,
I used to do my 24 hr urines from Litholink. But the latest one that my urologist ordered was from Mayo. The CaOx SS is listed as 2.15 DG (reference mean 1.77 DG) in the Mayo one. Is there a conversion factor I can use this to convert this to a comparable litholink type SS number, so that I can compare my latest result with my previous SS numbers from litholink?
Thanks
Josh
Hi Josh, I do not know how to convert from one to the other. It is a reason I use one or another lab but try to not mix them. Sorry. Regards, Fred Coe
Hi Josh, I do not know how to convert from one to the other. It is a reason I use one or another lab but try to not mix them. Sorry. Regards, Fred Coe
Dr. Coe, I am a long-time stone builder and having found your site just wanted to say how amazing it is for someone with your knowledge to give helps so freely to those in need. I can tell that those commenting probably feel the same way. You are a Godsend for those of us that have experienced much pain and worry. Many thanks!
Thank you, Mike; I hope your own prevention efforts have been effective. Fred
Are these computations okay with rats? We are working on an antiurolithiatic study and we will use rats as experimental animals. We will be analysing levels of calcium, oxalate, phosphate/phosphorus,pH, and volume in urine.
Hi Kc, indeed this has long been the case. Look up the publications by Drs David Bushinsky and John Asplin as excellent examples. Regards, Fred Coe
Here are the results from my recent 24-hour urine collection:
9.13 SS CaOx
90 Ca 24
42 Ox 24
661 Cit 24
1.70 SS CaP
7.344 pH
.03 SS UA
.361 UA 24
43 Na 24
76 K 24
80 Mg 24
.368 P24
24 Nh4 24
57 Cl 24
13 Sul 24
5.19 UUN 24
.9 PCR
1071 Cr 24
23.1 Cr 24/Kg
1.9 Ca 24/Kg
84 Ca 24/Cr 24
Hi Cathy, given the high SS CaOx and low values for both calcium and oxalate excretions (90 and 40 mg/d) I presume the urine volume is low. That your urine NH4 exceeds sulfate (SO4) makes me wonder about some loss of alkali – GI disease? Without more information, I cannot add more. Regards, Fred Coe
Hello Dr. Coe,
I wondering if you could give me some direction…..in your opinion, is it possible to correct, in a type two diabetic, metformin only Results from two 24 hour urine collections); extreme high calcium (300-400), Oxalate (50-61), citrate of (2400-2600), sodium WNL(101-117) all other “dietary factors from litholink were WNL’s , output 1.8 L then 2.8L, ph 5.4 & 5.9 with a Whole Foods plant based vegan diet? Especially if I drop dairy & fish and keep my blood glucose and sodium intake in excellent control? History of two stones in five years, one passed without intervention, last one with a cysto/laser litho & a five day stent.
Thanks for what you do!
Hi Kathleen, you do have very high urine calcium and oxalate. This even though your urine sodium is not that high. Diabetes itself can raise urine calcium, and also lead to your rather acid urine pH values. The high oxalate is from diet and perhaps low calcium diet. I would definitely use the kidney stone diet – with the low sodium that is part of that diet. Assuming urine calcium and stone risk persist I think you would do well with a thiazide type diuretic to lower the urine calcium. It will also help control blood pressure and protect bone mineral stores. Thiazide can worsen glucose tolerance, but if serum potassium is maintained – often this needs potassium chloride supplements – the effect is usually modest indeed. Regards, Fred Coe
Hi, Dr. Coe
I need help understanding the adjustments that LIthoLink has been making to the volumes of my 24-hr. urine samples. I understand that my reported volumes must be adjusted to fit a time period of exactly 24 hours, but that adjustment does not explain the differences I am seeing. I talked to my nephrologist about this, and he called LithoLink for an answer. The only explanation he got was for the time deviation from an exact 24-hr. collection period. I just noticed the differences recently when I had 2 more samples analyzed by LithoLink. When I went back to my notes on several prior tests and compared the volumes used by LithoLink for those samples vs. the volumes I actually reported, they also were different by an amount not consistent with the time deviation. In fact, in 2016 I reported a volume of 2.64 liters collected in 24 hrs. 0 minutes, and the volume used in my test report was 2.79 liters.
Here are the volumes for my last 5 tests:
Test Unex- Vol. used Vol. I reported, Vol. I Collection
Date plained in LithoLink corrected actually period
dif. report to 24 hrs. reported
3/19/18 -0.38 2.39 2.77 2.75 23 hrs. 50 min.
3/18/18 -0.08 2.40 2.48 2.65 25 hrs. 37 min.
10/5/17 0.07 2.31 2.24 2.20 23 hrs. 35 min.
10/4/17 0.09 2.65 2.56 2.62 24 hrs. 34 min.
8/9/16 0.15 2.79 2.64 2.64 24 hrs. 0 min.
The unexplained differences range from a negative 380 ml. to a positive 150 ml. They are in calendar order by size, but beyond that, they make no sense to me — will you please explain what’s going on?
Many thanks for your help and your time,
Pat
Sorry, the col. headings did not post as I expected. They are as follows: Test Date, Unexplained dif., Vol. used in LithoLink report, Vol. I reported – corrected to 24 hrs., Vol. I actually reported, and Collection period
Hi Pat, I can answer your question. Litholink puts a marker into the urine collection – a fixed amount of a harmless but detectable material and measures the concentration of that material in a sample of your urine. The concentration of the material in your urine is simply the total added (that is fixed by the company when you add preservative to the container)/volume of urine collected. One can calculate the volume from that amount (mg)/concentration (mg/l). Your reported volume is not the prime controller of the reported volume because trials by the company established that this dilution method gave more accurate results than you can get from reading your own volume using the scale on the container. Regards, Fred Coe
Very interesting!
So the graduations molded into the collection containers are not accurate enough to provide more than a rough estimate of the true volume, and the mysterious time trend suggested by my little analysis may have something to do with shrinking containers, but nothing to do with my kidney function . . . well, that’s a relief!
And that also explains why the LithoLink instructions say to add not only the contents of the preservative vial to the collection container, but also the vial itself and the cap — to make sure that every mg. of the marker gets in there.
Thank you so much, I will pass this info along to my doctor, and thanks again for this enormously helpful website.
Dear Doctor,
What is your opinion about Orthophosphate therapy (phosphorus) of Hypercalciuric stone formers due to IH?
I came along this paper: https://www.ncbi.nlm.nih.gov/pubmed/6893460
albeit an old paper and low number of patients, it shows a significant decrease in Urine Calcium and serum 1.25OHD3. In this paper they cannot explain this phenomenon.
Do you think is it because urinary Phosphate crystallizes with urinary Caclium in the urine and thus it is not detected as a free ion from the analyzer?
They also show a small increase in iPTH. Could this signify a detrimental effect on bone mineralization ?
Thank you.
Hi Doctor – I judge you are one; the work was very clever. phosphate loading lowered serum calcitriol, through a pathway well known even then, and also urine calcium. The authors reasoned the lower calcitriol lowered GI calcium absorption and also – perhaps by downregulating the renal CaSR – raised renal calcium reabsorption. PTH went up as expected. As for bone, no real data. Thanks for pointing it out. For clinical use, I would be wary. One can lower urine calcium and boost bone mineral balances with low sodium / high calcium diet, this measure has a very substantial trial, and indeed raising urine phosphate could possibly raise urine CaP SS and promote stones – though I doubt that happens. Regards, Fred
Hello Dr. Coe,
After reading your directions I am still unable to decipher my lab readings. Would you mind assisting me please?
11/12/17
Oxalate Urine
Vol 1.99
Creatinine Urine 3.9 mmol/L
24 hr Urine Creatinine 7.8 mmol/d 4.0-17.0
Oxalate 0.44 mmol/d H 0.04-0.32
17/12/17-18/12/17
Urine Biochemistry Timed urine Sample
Urine Volume 2.20
Creatinine Urine 24h 7.3mmol/collection N 4.0-17.0
Calcium Urine 24h 4.9mmol/collection N 2.5-7.5
Calcium/Creatinine Urine 0.67mole ratio H 0.06-0.45
My doctor told me oxalates are slightly raised but not enough to worry. I since raised my fluid intake to as close to 3L per day as possible. The urologist didn’t mention anything at all when I saw hime finally about 10 days ago. Then last week on a totally unrelated visit to my medical clinic another doctor said my oxalates are High! I am really confused now.
None of them are talking diet at all and I have had 3 hospital admissions with passing kidney stones in the last 2.5 years.
Is it possible to answer my query?
Kindest thanks
Jude
Hi Judith, The problem is that the lab article uses mg for oxalate and calcium and your labs are in millimoles – presumably not in the US. So your urine oxalate is 44 mg/d in US units and that is indeed high – risk begins at 25 mg/day. The usual reason is a low calcium diet. Your urine calcium is just at the lower edge of stone risk. Your urine volumes are barely adequate. So indeed urine oxalate is your main problem. The best approach is increased diet calcium to 1000 mg/day putting the calcium where higher oxalate foods are found. Then you need to lower diet sodium to about 1500 mg/day; this keeps urine calcium from rising. Finally, you want to be careful to avoid very high oxalate foods – list in the oxalate article. All this is the kidney stone diet, ideal for general health and for stone prevention. Regards, Fred Coe
My question is
How to recognise the type of kidneystone in ultra sound report without consulting the doctor???
Please tell a proper and clear ans
Hi Aswin, I would not advise this. You need physicians for stone disease. The ultrasound report is not a good index of stone type; you need to have the stones analysed. Regards, Fred Coe
Hi Aswin, I would not advise this. You need physicians for stone disease. The ultrasound report is not a good index of stone type; you need to have the stones analysed. Regards, Fred Coe
My most recent report, while on Potassium Citrate 15 meq twice daily for a year showed— urine calcium 42, oxalate 49, Citrate 482, ph 7.3. Supersaturation calcium phos 0.15, volume 4.91 L.
Because of the low numbers and extremely low supersaturations, a nephrologist advised me that I could stop Potassium Citrate completely. (My number was 334 before starting it), while my urologist advised increasing my dose of Potassium Citrate a bit.
Who to believe?
Hi Joyce, the low urine calcium and high oxalate suggest a low calcium diet – not ideal. There is no obvious basis for the potassium citrate, but I believe your diet is not ideal. Take a look and decide. Regards, Fred Coe
LithoLink Results
2.72 Urine volume
5.83 SS CaOx
244 Urine Calcium
34 Urine Oxalate
1519 Urine Citrate
1.48 SS CaP
7.01 pH
0.04 SS Uric Acic
0.39 Urine Uric Acid
44 Na
60 K
142 Mg
0.409 P
13 Nh4
52 Cl
10 Sul
4.44 UUN
0.6 PCR
934 Cr 24
14.2 Cr24/Kg
3.7 Ca 24/Kg
261 Ca 24/Cr24
Taking 1000mg Calcium supplement; allergic to dairy
Blood potassium 3.5 (at low end of range for months)
Taking 1/2 of 12.5 mg Thiazide since December 2017
Calcium oxalate stone confirmed by lab in 2015; no stones caught since then. Stone passed in January 2017. Seven stones on September 2017 CT. Ureteroscopy 2017 and shockwave 2018. Latest CT shows debris plus possible new stones.
Possible next steps–what makes sense?
1) Increase thiazide to half of 12.5/mg twice a day (this is double the current dose) to lower urine pH and urine calcium
2) Increase calcium supplement to 1250mg/day to reduce oxalate and lower urine calcium
3) Reduce oxalates in diet
4) Eat more protein to increase phosphorus and PCR and lower urine pH
5) Take potassium (NOT potassium citrate) to increase blood potassium; dosage? frequency?
Confused about why pH and urine citrate are so high.
Hi Susan, Of course I cannot practice medicine on the web, so my suggestions are for your personal physician to consider along with yourself. I presume your calcium supplement is calcium carbonate, and therefore provided an alkali load – not all the calcium is absorbed, all of the excess alkali is absorbed – so it is like potassium citrate in a way. Your diet is low protein – pcr 0.6 – not good for health. Your urine sodium of 44 mEq/d is very low! so I presume you have very marked underlying hypercalciuria. What is wrong is at base how you get your calcium. Perhaps you do not take it with your high oxalate meals – it needs to be highly selective. The urine magnesium is very high, sulfate very low suggesting a plant based diet – high oxalate, low protein. Perhaps you could reorient your diet along better lines. The ideal kidney stone diet is the ideal US diet, so that is always a good change. Perhaps you might want to discuss this with your physician before doing anything as I have a very imperfect knowledge of your actual situation. Regards, Fred Coe
I take cal/mag/zinc supplement (contains both calcium carbonate and calcium citrate) with meals. I am allergic to dairy. I also have severe osteoporosis. OK to boost calcium to 1250mg/day? Would increasing thiazide help? I will increase protein.
Hi Susan, You have a complex situation that I believe – I am far away!! – is genetic hypercalciuria with inadequate diet calcium and bone disease. I believe your urine sodium was very low – 44 mEq/d – and your diet is not fully clear to me. You need bone active medications if you have severe osteoporosis and also care from people specialized in mineral/ bone disease. At this stage we have to rely on your physicians and I had better keep quiet for fear of making things worse. Very likely mere change in diet calcium will not be enough to protect against fractures. Regards, Fred Coe
I have been working on my diet for 8 months and have successfully lowered my protein from 2.0 to 1.1. All my levels have come down. My Urine calcium was 346 now down to 259 my urine ph is 6.8 was 7.0 but one of my 24 hour urine test was 6.1. I do not want to go on medication. Should I just keep going as I am? My urine volume was 3.45 My oxalate was 39 but I know it was my diet as I previously had it down to 25.
Hi Clare, Here is a good article on exactly this issue. In general we treat the individual values to lower supersaturation, and if we do lower it we stay with the diet and fluids unless more stones form. Take a look. You seem to be doing rather well, it would seem. Regards, Fred Coe
Would you mind assisting me please?
My Stone Risk Factors /Cystine Screening:
½ days Vol 24 1.50/1.47, SS CaOx8.52/7.97, Ca 24 278/275, Ox 24 32/30, Cit 24 820/832, SS CaP 0.95/1.93, pH 5.617/6.078, SS UA 1.59/0.85, UA 24 0.615/0.727
Dietary Factors
Na 24 107/146, K 24 54/73, Mg 24 170/132, P 24 1.028/0.921, Nh4 24 32/33, Cl 24 114/155, Sul 24 36/37 , UUN 24 8.71/7.66, PCR 0.7/0.7,
Normalized Values
Cr 24 2451/2234, r 24/Kg 24.6/22.4, Ca 24/Kg 2.8/2.8 , Ca 24/Cr 24 113/123
Thank you
Hi Roman, I do not understand 1/2 days. Do you mean you collected 12 hour urines? If so, no one can interpret them. If you mean days 1 and 2, your volume is too low, CaOx SS too high, calcium too high. Since I know nothing about your stones or your life, that is all I can say. Check out the values in this article so you can see why I said things were too low or high. Regards, Fred Coe
My urine diagnosed report showed I have calcium oxalate crystalls present.I don’t know how much but my Dr advise me to drink more water … And he doesn’t told me to take any scanning…why??.. My urine pH level is 5.
So Dr what is your opinion…..
Hi Vishnumox, I presume you mean your kidney stone analysis showed calcium oxalate or perhaps your urinalysis report. They are not rare in normal people. If you have stones, I would advise getting fully evaluated to find the cause. If you have no stones, just finding the crystals is of uncertain significance. If it is a consistent finding, perhaps a CT scan is indeed of value. Regards, Fred Coe
Hello! My Dr had me do a 24 hr urine collection to check citrate and creatinine which was normal. I was under the impression that he was checking everything! He said to drink enough water. That’s my “prevention plan”. Shouldn’t I know urine oxalate level? I drink plenty of water, have recurring stones since I passed my first stone two years ago. Calcium oxalate. Why wouldn’t my Dr check me thoroughly? What do you recommend I do? I had lithotripsy, ER visit, ureteroscopy, and another litho scheduled. I have had enough of these stones and want to get to the bottom of this!
Hi Maria, Not all physicians use vendors that provide comprehensive 24 hour kidney stone panels. S/He may use hospital labs, or be constrained by contract to this lab or that. Physicians face a lot of restrictions these days. I would ask for comprehensive testing, and treatment based on it. I am sure your physicians will accede to that request. Regards, Fred Coe
Hello Dr Coe,
I have bilateral MSK as seen on ureteroscopy.I take hydrochlorothiazide and allopurinol pills daily and have CaOx mono and di.my urine calcium is still high(330) deCaLs has dropped but still high(5.14),preparedness now at 40,citrate very high and double since April at 366,deCaL remain high 1.84 24 on high 7.04 uric acid all normal sodium improved but still high 196 calcium/creatine 255 .my report says my high oN suggests infection or colonization idea splitting organism and low citrate a possible causes hypokalemia, Uti bowel disease or decrease kidney function. I expect a urine culture to be done in my visit to nephrologist in 2 weeks. Do you have any thoughts on my results? I have found most Dr s are at a loss in treating MSK challenged patients.
Hi Elan, if seen on ureteroscopy, MSK is indeed present. You have very high urine calcium, no doubt from idiopathic hypercalciuria; this is unless your physician has found another reason for the high urine calcium. I cannot understand what deCaLs is, not preparedness of 40, but the urine sodium of 196 is very high and will raise your urine calcium despite your drug. I do not see much of a role for allopurinol given what little I have in hand from you. The high oN is probably urine ammonia, and if high does suggest infection of a kind that can enlarge stones. Prevention of stones with MSK is like without except the sponges make it harder because stones form in them as in stagnant pools, so reducing urine calcium, as an example, is very important. Low diet sodium 1500 mg – will help your OHCTZ work better and reduce potassium loss, so perhaps you might add that. Regards, Fred Coe
Apologies for my terrible spellchecker errors and not proofeeading. Here are my corrections to my previous message::Ss CaOxhas dropped to 5.14, package dropped to 40,AS CaP 1.84,24 he oH increases to 7.048 with Litholinkinquiry such a high number suggests infection or idea splitting organism a d low cirate366 could also mean infection.is there a difference between a Uti and idea splitting organism? Litholinkinquiry mentions not recommending pot citrate despite low citrate because CaP is high.
Hi Elan, I think – despite lots of spelling errors LL is trying to tell you to have your physicians culture your urine in pursuit of bacteria that possess urease and can hydrolyse urea to ammonia. I agree; feel free to take your LL report and this note to your physicians so they can decode things and decide if cultures make sense. If you are indeed colonized as suspects, you could make struvite stones. Use your physicians for this, it is not something you can do yourself. Regards, Fred Coe
I have low citric acid and take potassium citrate now in tablet form. When I was first diagnosed after a 24 hour urine collection, I was prescribed Effer K (2 MEQ bid) and had taken it for almost a year and a half. I began to experience some discomfort in my bladder and went to my urologist. I did have some infection and was put on an antibiotic. I also had an xray which showed I had no stones as the doctor thought I might be passing some. At that time, my doctor also switched me to a flavored Effer-K which I could purchase cheaper from another pharmacy. It took me 2 months to realize that the flavored was really doing havoc with my bladder because when I stopped I felt better, but when I started again, things got worse, and it was all in the bladder (a swelling feeling, even pain in the urethra). I finally went off of it for 2 months and actually began to feel normal again. But at the end of November I did another 24 hour urine collection, and it showed I was still low in citric acid, so the doctor said he would prescribed the potassium citrate in tablet form (2 – 20 meg tabs taken bid). I was really encouraged by taking it in this form until about 9 days after I started taking it that the same feeling of swelling and hurt in the bladder that I have to take an AZO tablet to tolerate it, and sometimes that does not stop it completely. Would you have any idea of what is going on? I realize how important this medicine is to my health, and I have started changing my eating habits to eat more alkaline foods. But this pain and discomfort really puts a hindrance to the things I want to do.
Hi Marilyn, In general potassium citrates have no bladder symptoms, but I do have a thought. Sometimes, because they make the urine alkaline, they may foster crystal formation in the form of calcium phosphates. This happens when urine calcium is high, urine citrate is low and does not rise much with the potassium citrate, and therefore the high pH promotes crystals that cause frequent urination and can feel like infection. Ask your physician if S/He thinks this possible, and if so perhaps an alternative approach might be more effective. I am far away and have no real details but your physicians will. Regards, Fred Coe
Hello Dr. Coe,
I came across your page and if you could help interpret my results I would very much appreciate it!
SS CaOx 4.08
Urine Calcium 115
Urine Oxalate 28
Urine Citrate 173
SS CaP 0.95
24 Hour Urine pH 6.72
SS Uric Acid .10
Urine Uric Acid 0.5
Thank you!
Hi Stacy, I do not know your stone type, so I cannot say much, but given your results are rather benign I suspect their secret lies in your history – what you may have been doing, eating, etc when they formed. That “when” could be some years before their discovery. Since I am not with you to ask, you need to ask yourself. Think about periods of low hydration, use of supplements or any other non food, stress, and – given the range of life – whatever is hidden away. The present urine does not look like the one that caused the stones. Regards, Fred Coe
Dr. Coe –
Would you please comment on how to interpret the results of serum (blood) tests vs. urinary tests? In particular the levels of serum oxalate vs. urinary oxalate? If one is high and the other is low, what does that mean?
Thanks,
Mike
Hi Mike, Serum oxalate is a research procedure so all the measurements are in urine. In research settings we have measured both, but only to do rather arcane estimates of how kidneys handle the oxalate. Are you not the person who asked me to put the reddit site on my site as a recommended place for patients? If so, I had asked for the correct URL to post, but never got it. Regards, Fred
OXALIC ACID, 24 HR URINE 75.5 h. what it means
Hi Sam, lacking units the 75.5 cannot be interpreted. Was it perhaps mg/24 hours? If so, that is quite high. Low calcium diet, high oxalate intake, and even forms of primary hyperoxaluria might cause it. I would recommend your physician repeat the measurement along with all of the other measurements typically used in stone prevention. Regards, Fred Coe
Greetings from Texas, and thanks so much for sharing your knowledge in this way. I’m a 61-year-old first-time stoner–that didn’t come out right–who developed a 10 mm x 7 mm calcium oxalate stone, first evident two months after starting Ozempic and losing 20 lbs in that time. (Coincidence?) Removed via ureteroscopy. Ugh. My new goal in life is to avoid future stones. Can you blame me?
My urologist asked for a 24-hour urine collection, and results look unsettling. Here are the abnormal values:
Citrate Urine = 97 mg/day
Total Urine Volume = 1.31 L/day;
Sodium Urate = 2.99 (no units)
Uric Acids = 4.25 (no units)
All other values on the report are within normal limits, thank you.
Other than updating my advance directives and will, what can you offer by way of advice or guidance?
Thanks you again!
Hi Barry, The Ozempic is a GLP 1 agonist and might raise urine calcium, so a possible cause of the stone. Your urine shows almost no citrate and very low volume. You say other values are normal but urine normal values are legal documentation having to do with lab ranges and not with risk of stones. Here is a good article on the general subject. Regards, Fred Coe
24 HR test volume 1,450…..cal urine 7.9 curate 215…creatinne value 75.2. Electrolyte sod. 80 pad 25 chlorine 81. Palate 18 creatinnie value 69. Uric acid 34
Okay what does this mean.
Hi Pam, I would be happy to help but what you provide is not easy to figure out. The volume of 1,450 (ml/d?) is low for a stone former – 2.3 l/d is better. I do not know what …cal, curate pad Palate mean. The 7.9 could be urine pH but if so it is so extreme a value as to worry me. Urine creatinine is rarely 75.2. Can you write down the actual words that go with the numbers? Regards, Fred Coe
I am 72, a male and have a history of calcium oxalate kidney stones. I had a parathyroidectomy two years ago. I have been on a low sodium, low oxalate diet for several years. A 4/12/19 KUB ultrasound showed no hydronephrosis or renal stones. I take Losartan for blood pressure.
The results (5/6/19) for 24-hr. urine collection showed a stable and high volume at 2.62L, a decrease in sodium to 160, and a decrease in oxalates to 41mg/d. Calcium was 225. The citrate remains stable and high at 1105. Urine pH was 5.733.
I have been increasing my dietary calcium due to osteopenia. Calcium was 6.7 mg/dL ion my last Comprehensive Metabolic Panel (3/26/19).
My urine pH has fallen from 6.655 (3/5/19) to 5.733 (5/6/19). Should I be concerned?
For several years I have taken Losartan (an ARB) for hypertension without any side effects. Because oxalate is an organic acid found in plants, but can also be synthesized by the body, I don’t know that I can realistically reduce my oxalate level more by diet alone. Could changing to a thiazide diuretic be effective for the further lowering of my oxalate level as well as reducing hypertension?
Is potassium citrate an option for reducing oxalate without elevating my potassium level? My urine potassium was 87mmol/24 hour (5/6/19).
Hi Brian, Your parathyroidectomy appears to have caused hypoparathyroidism, or else your bones are taking up a lot of calcium, because your serum calcium is very low at 6.7 mg/dl. Your urine pH has fallen with surgery because PHPT raises urine pH and that disease is now gone. Your urine calcium is very high given the low serum calcium, suggesting you have very low serum PTH levels – perhaps undetectable. As for stones, ultrasound is so bad at detecting them I shun the procedure in favor of ultra low dose CT. The 41 mg/d of urine oxalate poses some stone risk, and high calcium diet can help but only if the extra calcium is taken with the larger meals that are apt to contain oxalate. Endogenous production is rather low. Thiazide nor potassium citrate will alter urine oxalate in humans, but both will lower urine calcium. I would favor thiazide if you are producing new stones, but you cannot tell sans a CT. Your urine citrate is already so high that supplements would be without purpose unless your lower urine pH leads to uric acid stones. The combine of high urine citrate and low urine pH suggests early insulin resistance, so I would be sure my fasting serum glucose was normal. For blood pressure losartan is far preferable to thiazide – less side effects. Regards, Fred Coe
Dear Dr. Coe,
With respect to my fasting blood glucose, my hemoglobin A1 c was 5.2% on 4/15/19. I believe this is at the high end of the normal range.
Due to a diagnosis of osteopenia and low D3, I am taking a D3 supplement, 3,000IU daily as prescribed by my internist.
Would hypoparathyroidism be treated by an endocrinologist?
Thanks very much for your assistance.
Hi Brian, Indeed it would be best with such a physician. I would recommend you consider that. Regards, Fred Coe
I am a 49 yr old female who has experience 3 bouts with kidney stones. Recently did the 24 hour test and these portions came back a out of range.
Total Volume .98L
Uric Acid 751
Calcium Oxalate 2.18
Brushite 4.28
Sodium Urate 8.68
Unfortunately, I do not know what type of stones I had in the past. I do know I have one currently growing…yet again. My last stone was in 2017 and was broken up by lithotripsy. It was reported as being 6mm in size.
I am very active, drink upwards of 1 gallon of water a day. I dont drink alcohol(allergic, yes its very sad) I consume very little dairy(allergic) and almost no fruits and vegetables(allergic) I consume mostly Chicken, Pork, and Venison.
I do have a follow up with my physician, Just looking for other thoughts?
Hi Sharon, The high serum urate is eye catching in a midlife women. Is your blood pressure normal? Likewise the brushing SS of 4.28, if that is indeed a supersaturation measure. If so your urine must be very alkaline, or calcium quite high. So I do not understand how everything can be so in range. The secret is the volume – 0.98 L/d. That is a very low number, so low it can produce stones of any make or model. You may drink a gallon of fluids but your kidneys are telling you they are very short on water and are conserving every drop. Or, possibly, the sample was very inder collected. This latter is unlikely given the high uric acid excretion. Note – to have that much uric acid in 0.998 l of urine the pH is indeed high. Does any of this help? Regards, Fred Coe
I have read your information and find it real good. My question though is how to read the report the doctor gave me. It has 22 different numbers with the abbreviation, like SS CaOx, Ca24….
Is there somewhere I can read what the abbreviations mean, so I can refer to them while reading your information?
Frank
HI Frank, The article you wrote on does really say how to do it. SS means supersaturation. Ca24 is 24 hour urine calcium. If what I wrote is not clear enough, shame on me. I tried. Let me know, Fred
Hi I have had 4 calcium oxalate stones. I recently did my 24 hour test. I would love for any feedback you may have as the only advice i have been given is to drink more water.
Volume was 2.10
Creatinine 4.6 mmol
Creatinine (24hr Urine) 9.7 mmol
Oxalate (urine) 106 umol/L
Oxalate (24hr) 223 umol/L
Urate 0.9
Urate (24h) 1.9
Calcium 3.61 mmol
Calcium (24hr) – HI – 7.58 mmol
Sodium 42 mmol
Sodium (24hr) 88 mmol
Parathyroid Hormone Intact – 6.2 pmol
Citric (urine) .84 mmol
Citrate (24hr) 1.8 mmol
Hi Susan, Your urine volume is just adequate, calcium is quite high, sodium is reasonable if ample and citrate low. I would think your physicians might want to raise your urine volume and ask you to lower your already reasonable diet sodium further to lower your urine calcium. If that is not enough, potassium citrate might be of value as it will lower urine calcium and also provide citrate. Of course your physician is in charge here, and these are just suggestions to that person – and you. Regards, Fred Coe
thank you …….much appreciated
Can you explain what the Normalized Values ca24/cr 24 mean in the 24 hour results. Someone on the Facebook page said that their doctor looks at that rather than looking at the urine calcium value at the top of the report. My urine calcium was high at 414, but my ca 24/cr 24 was 165.
Any significance there?
Thanks,
Morris
Hi Morris, the normalized values attempt to allow for sex and body size in determining if a urine value is abnormal. But in your case things are easy. Your urine calcium is so high it poses stone risk and stone prevention will require that you find ways to lower it. Here is my best on this subject, see if it helps you. Regards, Fred Coe
Thank you so much for the reply!!!
Sir just wana to weather these investigations in spot urine
Hi pankaj, spot urines are not worthwhile. Urine chemistry changes with meals too much, and all we know about risk vs urine chemistry comes from 24 hour urines. The cost of running the tests is the same for a spot as for a 24 hour urine. Regards, Fred Coe
Hello, Trying to figure out where I should go next. Had Kidney Stone in March, Removed by Urologist in April, Stent removed in May. Parathyroid levels were 75 in March, 57 in June and 67 in Aug. Urologist called and told me my 24 Hr Urine came back high for Calcium. Referral to ENT for possible Parathyroid removal. He said all levels were within normal range. Sent for Thyroid Ultrasound that showed probable Chronic Lymphocytic Thyroiditis and no definite Parathyroid lesion.
Volume 1.66 Na 24 141 Cr 24 1510
SS CaOx 10.94 K 24 59 Cr24/kg 13.2
Urine Calcium 726 Mg 24 200 Ca24/kg 6.3
Urine Oxalate 31 P 24 1.493 Ca24/Cr24 481
Urine Citrate 681 Nh4 24 51
SS CaP 1.99 Cl 24 144
24 Hr Urine PH 5.511 Sul 24 66
SS Uric Acid 1.65 UUN 24 13.73
Urine Uric Acid 0.613 PCR 0.9
Hi Colleen, Your urine calcium is indeed remarkably high and PHPT is not unlikely. Here is a review of that disease. Serum calcium, not scans, are the crucial thing. Get them fasting, in the morning, and ask if multiple readings are above the upper limit of normal – usually about 10.1-10.3 mg/dl. Given a PTH level that is not suppressed and so very high a urine calcium I would suspect this disease. Regards, Fred Coe
I am wondering how a person could possibly produce more than 2 liters of urine a day. Since being diagnosed and treated for kidney stones, I have done two 24hr urine samples analyzed for stone risk factors, two months apart. My first sample had a 24 hr volume of 800 ml. My second sample had a volume of 1,400 ml.
Between samples, I altered my diet to force myself to drink more liquids, reduce dietary oxalate, and increase dietary calcium. I began taking TheraLith ( contains 180 mg of magnesium citrate and magnesium oxide 50/50 plus B6 and 99 mg potassium per two pill dose ) twice a day as a supplement. I did not alter my meat/protein intake, which includes one of the following, daily: beef, pork, chicken and fish. I use “light salt” ( NaCl and KCl blend ) in moderation.
I was pleased, but confused with the results. My 24 hr urine pH went up from 5.5 to 6.8. My 24 hr urine calcium went from 150 to 252 mg. 24 hr urine oxalate went down from 40 to 27 mg. 24/hr uric acid went up from 448 to 504 mg. Uric Acid went from 450 to 850 mg(!) 24 hr urine sodium went from 75 to 162 mg. 24 hr urine sulfate went from 22 to 17 mg. 24 hr urine phosphorus went from 882 to 875 mg. 24 hr urine magnesium went from 100 to 159 mg. 24 hr potassium went from 48 to 54 mEq. 24 hr urine creatinine went from 1325 to 1222 mg. Calcium oxalate went from 4.41 to 1.82. Brushite went from 1.31 to 5.22 (!!!!) Sodium urate went from 2.55 to 3.29 Uric acid went from 5.30 to 0.28.
Supersaturation indices for the first sample were:
Calcium oxalate
Monosodium urate
Uric acid
With the “Suspected Problem” being stated as “Uric Acid Lithiasis”
Supersaturation indices for the second sample were:
Brushite ( Calcium phosphate )
Monosodium urate
With the “Suspected Problem” being stated as “Hypercalcuric Nephrolitiasis”
I am a male, currently 69 years of age. At approximately age 30, I had two bouts of kidney stones, which I passed, and which were sent out for analysis. They were small stones ( 2 mm ) described as being composed of calcium oxalate.
The stone that formed in my renal pelvis this year was 7mm and was successfully treated with ECSL. Unfortunately, no stone material was recovered for analysis.
So, I am left wondering: Do I potentially have a propensity to form all three types of stones? And if so, how do I control dietary factors to limit my risk, and still try to eat a healthy diet? (Oxalate restrictions* alone are draconian, excluding from the diet an awful lot of things considered “healthy”, for example, in a diet designed to lower CAD risk. ) Finally, how can one practically produce >2 liters a day of urine? Pushing myself to drink, I can not even achieve 1.5 liters, and I am a fairly active 69 year-old.
Thanks for your advice with renal stone prevention.
*By the way, I have carefully researched the data on oxalate levels in foods, and I have found WIDE variations from studies performed at several well-regarded universities and the American Dietetic Association. I have even found outright contradictions, with one study reporting some foods as “extremely high” in oxalates, with another equally-plausible study reporting those same foods as “low” in oxalates.
Hi Gerald, Here are your changes: My 24 hr urine pH went up from 5.5 to 6.8. My 24 hr urine calcium went from 150 to 252 mg. 24 hr urine oxalate went down from 40 to 27 mg. 24/hr uric acid went up from 448 to 504 mg. Uric Acid went from 450 to 850 mg(!) 24 hr urine sodium went from 75 to 162 mg. 24 hr urine sulfate went from 22 to 17 mg. 24 hr urine phosphorus went from 882 to 875 mg. 24 hr urine magnesium went from 100 to 159 mg. 24 hr potassium went from 48 to 54 mEq. 24 hr urine creatinine went from 1325 to 1222 mg. Calcium oxalate went from 4.41 to 1.82. Brushite went from 1.31 to 5.22 (!!!!) Sodium urate went from 2.55 to 3.29 Uric acid went from 5.30 to 0.28.
You took alkali so urine pH went up. You added diet calcium but did not lower urine sodium – raised it! – so urine calcium went up. You tok magnesium so magnesium went up. You added calcium, so urine oxalate went down. The CaOx SS fell because oxalate fell, the BR SS went up because urine pH and calcium went up. The big problem is that you did part of but not all of the kidney stone diet. It requires increased diet calcium AND lower diet sodium both together. As for diet oxalate, you no longer have a problem as diet calcium cured it – as it almost always will. Most lists are corrupt, ours is as best we can get it given an excellent source (Harvard) and a wonderful curator (Ross Holmes). Regards, Fred Coe
Thanks, Dr. Coe,
I will work on my sodium intake, but I can tell you, I ingest very little to begin with. I am skeptical that lowering it any further will be of much value. What is the mechanism by which lowered urine sodium affects urine stone-forming chemistry?
Also, I did not increase my dietary calcium intake at all between my two 24 hour urine collections.. I take no calcium supplement, and what calcium I ingest comes solely from dairy products, which I eat only in moderation. Increased calcium intake cannot possibly account for the reduction in my oxalate values. Not only that, but my latest results indicate that I am now at risk of “hypercalciuric nephrolithaisis”. Out of frying pan and into the fire? I think that the reductions in urine oxalate and calcium oxalate are a reflection of my rigorously following a low-oxalate diet… which is not easy.
1. Having “solved” the oxalate problem that I would expect to have given rise to calcium oxalate stones, I appear to have somehow traded this off with radically increased brushite ( calcium phosphate ) levels. I assume that this is due to a shift in urine pH. You did not comment on this. Am I now at risk of forming calcium phosphate stones? If so, will reducing my intake of sodium impact brushite concentrations? If not, what will impact ( lower ) them?
2. I continue to struggle with the recommendation to produce > 2,000 ml of urine per day. I managed with persistent effort to increase my diurnal output from 800 ml to 1,400 ml. I have read the example fluid intake suggestions in the diet section of this website and find them extremely unrealistic. If I can normalize my supersaturations at an output of 1,500 ml per 24 hours, is there any reason to produce more urine ( other than the fact that “more is always better” )?
I need to find a way to consistently eliminate all possible supersaturations. I seem to be only halfway there, at best.
Thanks again for your advice!
Dr. Coe,
I want to apologize for making two seemingly contradictory remarks in my sequential comments in this blog regarding my calcium intake. In my first message, I indicated that, along with making other dietary changes between two 24 hour urine collections ( which were separated by a 2 month timespan ), I had increased my dietary calcium. I actually tried to do so, but I don’t think I was very successful, as measured by any significant increase in dairy products or other calcium-rich foods. So, when I noted in my last comment here that I had, in fact, not increased my calcium intake, I was using that frame of reference.
Hi Gerald, I saw this after my note. Diet oxalate may have been the main factor lowering your urine oxalate. The sodium raised your urine calcium. Best, Fred
Hi Gerald, I copied your prior results below for reference. You raised your urine sodium from 75 to 162 mEq/d, and urine calcium varies quite a lot with urine sodium in that range. Renal sodium excretion must match diet sodium because there is little storage space for sodium, so very powerful and evolutionarily conserved mechanisms link them. Calcium handling by the kidney parallels sodium in the early parts of the nephron, and although they are separated more distally the sodium effect is remarkable and very well established. You have been labeled ‘hypercalciuric’ because your urine calcium rose. You say you did not increase your diet calcium but you said you did: “Between samples, I altered my diet to force myself to drink more liquids, reduce dietary oxalate, and increase dietary calcium. I began taking TheraLith ( contains 180 mg of magnesium citrate and magnesium oxide 50/50 plus B6 and 99 mg potassium per two pill dose ) twice a day as a supplement.”. You also took alkali, as I noted in my first response and that raised the urine pH, so the calcium phosphate supersaturation rose, as you noted. Of course lowering diet sodium back down to around 75 will lower urine calcium, but the alkali raise urine pH. The purpose of the alkali is to raise urine citrate, but you do not say if it went up; I suspect the pH went up more than citrate as the SS for CaP rose and it is strongly lowered by citrate that binds calcium. As for urine volume, it is hard to control supersaturations with less than 2 liters of urine, and in the only prospective observations stone risk begins to increase below 2 liters/d. I said before you need the whole kidney stone diet to get anywhere, and your situation illustrates the problems people have implementing it. Sometimes is it just to hard, and physicians use medications. I hope this helps clear up what appear to have been less than ideal answers from me the first time. Regards, Fred Coe
My 24 hr urine pH went up from 5.5 to 6.8. My 24 hr urine calcium went from 150 to 252 mg. 24 hr urine oxalate went down from 40 to 27 mg. 24/hr uric acid went up from 448 to 504 mg. Uric Acid went from 450 to 850 mg(!) 24 hr urine sodium went from 75 to 162 mg. 24 hr urine sulfate went from 22 to 17 mg. 24 hr urine phosphorus went from 882 to 875 mg. 24 hr urine magnesium went from 100 to 159 mg. 24 hr potassium went from 48 to 54 mEq. 24 hr urine creatinine went from 1325 to 1222 mg. Calcium oxalate went from 4.41 to 1.82. Brushite went from 1.31 to 5.22 (!!!!) Sodium urate went from 2.55 to 3.29 Uric acid went from 5.30 to 0.28.
Between samples, I altered my diet to force myself to drink more liquids, reduce dietary oxalate, and increase dietary calcium. I began taking TheraLith ( contains 180 mg of magnesium citrate and magnesium oxide 50/50 plus B6 and 99 mg potassium per two pill dose ) twice a day as a supplement. I did not alter my meat/protein intake, which includes one of the following, daily: beef, pork, chicken and fish. I use “light salt” ( NaCl and KCl blend ) in moderation.
Dr. Coe,
I just received my results and then wen tot read this page and I am totally confused. I am hoping you can shed some light. The PH is high ( I dont eat much much) and the citrate is low. I am wondering if you can shed some light before I go crazy here.
Thank you.
Volume 3.47
SS CaOx 2.85
Urine Calcium 174 Mg
Urine Oxalate 23 mg
Urine Citrate 427 mg
SS CaP 0.87
24 Hr Urine PH 6.986
SS Uric Acid 0.03
Urine Uric Acid0.363
Na24 70
K 24 44
P 24 0.463
Nh425 32
Cl 24 80
Sul 24 <10
UUN 24 4.43
PCR 0.7
Cr 24 966
Cr 24/Kg 18.5
Ca24/kg 3.3
Ca24/Cr 24 180
Hi Natalie, The low citrate, high pH, and high urine ammonia (NH4) point to your being a calcium phosphate stone former. Our most recent research describes exactly that pattern in such patients. Do you form calcium phosphate stones- apatite or brushite? I cannot find your entire set of questions as WorkPress is not so good at that. The very low sulfate points to a low meat intake which means a low acid load, so your ammonia is way too high as is present in calcium phosphate stone formers. Given your high urine volume and low SS I suspect you are not making new stones, so the results are not of immediate clinical import. Regards, Fred Coe
Dr. Coe,
I have had one attack and my stones were never seen on any scan. Nor caught. And I recently had more scans (US/MRI) for other things and nothing seen either. But I am extremely nervous and want to know how I can stop this from ever happening again. What can I do about the high PH or low Citrate? My blood potassium is fairly normal. But I am assuming diet is the best way to combat these things? I am just so stressed out.
The report mentioned: Mild hypocitraturia. If this is the only metabolic defect consider treatment with potassium citrate 20 to 60 meq per day in 2 to 3 doses. If pH is above 6.3 monitor SS CaP, hypercalciuria may need to be treated to avoid CaP stones. Hypokalemia can cause hypocitraturia.
Thank you for all you!
High urine pH. High urine pH can promote calcium phosphate stones. When coupled with low urine citrate
consider distal renal tubular acidosis. When using alkali supplements (citrate or bicarbonate) manage urine
volume and urine calcium to maintain SS CaP less than 2.0.
I should also add that my younger sister has Barrter’s Syndrome. We are both in our 40s. Does this mean I have distal renal tubular acidosis or Barrters? I just dont know what to do. I dont meet with my urologist until after the New Year.
Hi Natalie, The Barrter’s in your sister is important. Do you have, perhaps, slightly low serum potassium? There are five flavors of Barrter’s syndrome, which one she has matters. You probably should have a renal expert as one of your physicians, as I am sure you sister has. Regards, Fred Coe
Hi Natalie, You have low urine citrate and high urine pH. I wrote the report algorithm when I owned Litholink – sold it in 2006 – and can tell you that this is quite possibly a cause of your stones – if they are indeed calcium phosphate. Citrate supplements have never been tried in a proper trial for people like you so I do not know if they are right. Renal tubular acidosis causes abnormal blood values, and I gather your blood tests are normal. I gather urine calcium is normal – 200 mg/d or less. High fluids are the safest bet, about 3 liters a day, and be sure about the blood. Your physician will know what to order. The advice about alkali supplements – originally mine! – is alright, with the proviso I already mentioned and the precaution in the note you copied. Regards, Fred Coe
Dr. Coe,
I went back to review the numbers and the Nh4 24 (Urine Ammonium) is at 32. I added an extra number in there. It is in the green section of the test as the range is from 15-60. Does this change things?
And all my correlating blood work from Labcorp (Calcium serum, PTH, Phosphorus and PTH) all are normal.
Sorry for all the add-ons!
Again, many thanks for you do.
:)Natalie
Hi Natalie, urine ammonia is interpreted as against urine sulfate, it should be a bit below the sulfate. Of the serum labs, the key ones are chloride, potassium, and total CO2 content. I presume they are normal, but be sure. Fred
Hi Dr. Coe…I’ve been reading your articles for months now (my son started excreting high calcium and other minerals in the beginning of May). I really appreciate all of the information and insight you provide and I was prompted to write after reading so many of your responses. Please forgive the length of my comment. 🙂
My son was 4-years old (he’s now 5.5) when I saw a very bright white stain on his underwear where he had a little pee come out as he was about to use the toilet. Small drops fell on my bathmat, which also turned bright white when dry. This continues to happen most nights, although the most dramatic presentation was the first night I saw it. (Interestingly, I saw the appearance of them directly after giving him a medication for the first time, aminocaproic acid (Amicar). He has mild von Willebrand Type I bleeding disorder and had 2 significant nosebleeds in which I had to give him the medication for several days. Amicar was stopped and the first stain happened that evening. I can’t say for certain if it was occurring before this date, but I never saw anything like it before and find it to be very coincidental.)
I also noticed his urine was extremely cloudy with visual sediment in the toilet. Initial visits with pediatricians showed normal UAs except many crystals were seen. The Dr.s and RNs we saw had never seen white stains in underwear before.
After being referred to urology, he had a random spot urine test and his calcium/creatinine ratio was .42. A renal ultrasound was ordered and showed his kidneys looked good but bladder debris were seen. A 24-hour urine collection test through LithoLink was ordered and confirmed hypercalciuria. His Calcium 24 was 13.6/mg/kg, Creatinine 24 was 21.6 mg/kg and Ca 24/Cr 24 was 633.
Because the calcium was so high, they associated the white stains to extreme calcium levels and determined they are calcium deposits from dried urine.
His urologist ordered a barrage of bloodwork, a bone density test and an additional renal ultrasound. All seemed unremarkable, although bladder debris was still seen. Since he was not experiencing any noticeable symptoms, other than my report that he has been tired and sleeping more, we took a natural approach and he started drinking lime juice to increase his acid level to try to bring his calcium and PH levels down (PH was 6.98).
He did a 2nd 24-hour collection a month later and we had encouraging results. However his creatinine and oxalate were starred by the lab. Creatinine dropped significantly from 338 mg/day to 193 mg/day and the note said there was significant variation in the test (I may have missed a midday void, so I associated that with the reduction). And after doing some research I figured the oxalate level was starred as it did not move much, and the Ox/Ca ratio doubled from .04 to .08 (it was 36.8 mg/1.73 m2 /day on the 1st and 39.2 on the 2nd). However, a major reduction in calcium was seen (7 mg/kg/24), so we increased his lime intake from the juice of one lime to two a day.
Another 24-hour collection was ordered to test the effectiveness of the increased lime juice and my son was asked to be part of the stone clinic (Dallas Children’s Hospital). The nephrologist found that the crystals in his urine are mostly calcium-phosphate.
The 3rd collection showed a marked increase in his Ca 24 (11.5 mg/kg/24) and some strikingly different results, showing much higher levels of oxalate, uric acid and phosphorous in his urine. His creatinine was inconsistent again, which the lab noted along with his oxalate level again, which rose dramatically to 137.5 mg/1.73m2/24. And again his Ox/Cr increased… to 1.2.
I did some research and found that ascorbic acid can increase oxalate, so we stopped the lime juice completely so we could get a good base level for the 4th collection. We also tested blood oxalate and ordered a hyperoxaluria urine panel through Mayo. We waited 10 days after stopping lime juice on blood draw. The blood oxalate came back high at 6.2 umol/l but the hyperoxaluria panel wasn’t remarkable. We re-did the blood oxalate at 2 different labs and hyperoxaluria panel again about 3-4 weeks later, this time with all results normal thankfully.
The 2nd oxalate blood testing was done the morning his 4th 24-hour urine collection ended. The 24-hour urine for the last test came back with a normal creatinine level, but the calcium stayed the same (11.4) and the urine oxalate was still high (88.3).
During this whole process he has had multiple labs on PTH, Ionized Calcium, Vit D 25 and 1-25, renal function panels and more, all of which I’ve been told are normal.
The last 24-hour collection was resulted a few days ago and we are now going to be doing genetic testing, more blood work, additional ultrasounds to make sure he hasn’t started forming stones and additional bone scan to make sure his bone density is still looking good.
I’m writing to see if you see these numbers and anything stands out to you. If so, do you have any suggestions beyond what we are doing? Below are some of the #s from the 24-hour collection (top line is the latest). I noted that the Sodium and Chloride increased substantially on the last test, but I can’t think of anything significantly different in his diet that day. I’ve been trying to keep everything very well balanced since all of this started.
Date SS CaOx Ca 24 mg/kg Ox 24 mg/1.73 m2 Cit 24/Cr 24 pH UA 24 g/1.73 m2 P 24 mg/kg Mg 24 mg/kg
11/18/2019 10.27 11.4 88.3 975 7.288 1.32 36 4.8
09/03/2019 13.86 11.5 137.5 762 6.975 1.82 45 6.3
07/29/2019 4.30 7.0 39.2 1421 6.812 0.60 27 3.0
06/24/2019 7.80 13.6 36.8 628 6.983 0.91 29 4.6
Date Vol 24 L/d Ca 24 Ox 24 Cit 24 SS CaP SS UA UA 24g/d
11/18/2019 1.24 190 37 350 3.50 0.05 0.548
09/03/2019 1.37 189 56 * 361 3.34 0.14 0.748
07/29/2019 1.47 116 16 * 275 1.74 0.06 0.246
06/24/2019 0.93 214 15 212 5.16 0.10 0.364
Date Na 24 mmol K 24 mmol Mg 24 mg P 24 g/d Nh4 24 mmol Cl 24 mmol Sul 24 meq/d UUN 24g/d PCRg/kg/d
11/18/2019 158 57 79 0.597 12 144 27 5.80 2.4
09/03/2019 87 64 104 0.743 28 75 43 8.76 3.5
07/29/2019 43 43 50 0.455 10 46 13 4.05 1.7
06/24/2019 82 30 72 0.451 12 75 20 5.65 2.4
Date Weight in Kg Cr 24 Cr 24/kg Ca 24/Kg Ca 24/Cr 24
11/18/2019 16.6 359 21.6 11.4 528
09/03/2019 16.6 473 28.7 11.5 399
07/29/2019 16.6 193 11.6 7.0 600
06/24/2019 15.7 338 21.5 1 3.6 633
Below are some blood results:
Date Creatinine mg/dL BUN mg/dL Na mEq/L K mEq/L Chloride mEq/L CO2 mEq/L Ca2 mg/d Ionized Ca2 mg/dL
June 27th .34 17 142 4.9 103 20 10.3 –
July 3rd .31 13 141 4.5 103 19 10.3 5.4
July 26th .52 20 140 5.0 106 26 10.2 –
Oct 23rd .31 9 140 4.0 105 28 10.2 5.17
Date Ph mg/dL Albumin g/dL Mg mg/dL PTH, Intact pg/mL Vit D, 25 ng/mL Vit D, Total 1,25 pg/mL
June 27th 4.5 4.8 – 22 – –
July 3rd 4.7 4.7 2.3 23 44.1 63
July 26th – 5.1 2.2 – – –
Oct 23rd 4.9 4.4 2.1 15 39 70.9
Sorry again for the lengthy post, just wanted to put it all out there at once. And I appreciate any insight you may have.
Thanks again!
Hi Nichole, Your son has presumably severe genetic hypercalciuria and high urine ph therefore forming abundant calcium phosphate crystals. He is at a top medical center in Dallas, where no one will miss anything. His blood calcium and Mg levels appear normal – fasting I presume, his chloride and CO2 seem variable from 20, 19 to 26, and surely the Dallas folks are being careful to be sure the CO2 is not low – that would be renal tubular acidosis. The variations in urine creatinine are due to variations in completeness of collection, and do not mean anything more. A number of specific genetic disorders can cause what your son has, but given the excellence of the institution I am sure all have been thought of and excluded leaving the common idiopathic hypercalciuria – that can be quite marked. Low sodium diet and low doses of thiazide have been used in children with this condition, and I guess they will be recommended. The high urine pH is probably genetic and related to renal ammonia production and perhaps intestinal anion absorption – our newest work, or alternatively to renal tubular acidosis. But the latter seems unlikely given the normal looking blood data. All of my comments will seem trivial to the Dallas staff, but possibly you might mention them in passing. I am perfectly confident in their ability – a wonderful institution. Regards, Fred Coe
Thank you very much for your response, Dr. Coe. I really appreciate it. And I feel very lucky to have a great team working with my son.
You mentioned fasting levels of certain blood tests. He only fasted for the blood oxalate testing, no other tests are fasting levels. Does fasting make a significant difference? I have requested the next bloodwork, being done this week, be fasting this time around. I’m also going to see if I should stop his daily vitamin supplements prior to testing, which I did for the oxalate blood test only.
Out of curiosity, have you seen the symptom of a large number of white crystals in underwear before? Not sure if I’m allowed to post a link here, but if so, here are some images (if not, I can remove it): https://www.dropbox.com/sh/b486wquct5mqrip/AACsVSgmBwPAVjiQLebswVJaa?dl=0 It happens almost nightly (at least 5 days/week) at varying degrees, sometimes very faint and sometimes very white.
Because this started happening when I gave him Amicar (for his nosebleeds) for the first time, I have been researching the renal complications of aminocaproic acid and lysine derivatives. There are isolated reports about more acute renal reactions that dissipated after discontinuing the drug, but nothing ongoing after stopping it.
I would be interested to see if aminocaproic acid could make urine PH rise quickly…I haven’t really looked into that aspect of the medication. Would a significant rise in urine PH cause a more extreme level of calcium phosphate crystals if he was already prone to high calcium excretion? I’ll talk to his nephrologist about this too…I’m just constantly trying to gather more information since the calcium level is so high and it seemed to start right when taking the medication.
And thank you for linking your new research on acid-base handling…very interesting to learn about. Is there a full-text link available to share? If not, no problem.
Thank you again for your response and for sharing your confidence about the team we’re working with. It is comforting.
Thanks again,
Nichole
Hi Nichole, Calcium phosphate crystals can show up as deposits as in this situation. Any rise in urine pH will raise supersaturation for calcium phosphate, but I do not know if Amicar does this. Amicar can cause kidney failure – this article mentions multiple causes though it focuses on a rare situation. A search of PubMed for ‘Amicar AND renal tubular acidosis’ yielded only two papers on its use in sickle cell anemia, a known cause of renal tubular acidosis and high urine pH. So I do not think the drug is culprit here. Regards, Fred Coe
Hi Dr. Coe,
Thank you so much for responding and sharing the article/feedback. I appreciate you looking at the results of the search!
Interestingly, my son’s uncle (on his Dad’s side) has sickle cell trait (parents/grandparents are from southern Spain). He’s always been slightly anemic with low hemoglobin and hematocrit…and after the nosebleeds when I first gave him Amicar, I took him to his hematologist, and he was iron-deficient anemic. His Von Willebrand Type I is quite mild, but he is still deficient in VWF and Factor VIII. I assume tests for sickle cell disease happened when he was born, but since he has a bleeding disorder and low hemoglobin, I’m interested to see if this could interfere with that test.
He also had many tests last Friday, this time fasting (thank you for mentioning that again). Due to a slightly increasing ionized calcium level along with a small rise in PTH levels, he is getting referred to endocrinology for suspicion of the parathyroid not functioning correctly, since it’s not lowering as calcium rises. With his age and pretty low PTH levels overall, I think it would be surprising if he had primary hyperparathyroidism, which I’ve read can cause some of the symptoms he is having. However, they are still reaching out to endocrinology to review.
There have been additional tests that have come back over the last couple of days. The ones I’m most interested in learning more about are those now slightly out of range or showing trends. (Note: I forgot that the July 26th blood results that I shared above were from a different laboratory….the patterns below are all from the Children’s Dallas laboratory and do not include the numbers from the outsourced one, which was Quest labs).
Vit D 1,25 Dihydoxy is 83.5 pg/mL with an upper limit of 79.3 for the lab. It has risen from 63 -> 70.9 -> 83.5 over last 3 tests. His Vit D 25 Hydroxy is 42 ng/mL, so still in the normal range (it’s been pretty similar over the last three tests….44 -> 39 -> 42).
Total serum protein is 8.3 g/dL (previously 7.6)…with an upper limit of 8 at this lab.
Magnesium serum level decreased to 1.9 mg/dL (2.3 -> 2.2 ->2.1 -> 1.9), but is still in the normal range with a lower limit of 1.6.
Phosphorous serum increased to 5.3 mg/dL (4.5 -> 4.7 -> 4.9 -> 5.3) but still in the normal range with upper limit of 5.4.
He had amino acid plasma and urine tests…I can’t see the urine results, but the notes say nothing abnormal stood out. The only level that I’d like to learn more about (I won’t be able to discuss results until next week) is his plasma level of Phosphoethanolamine, which is <5 micromol/L (the range is <=69 micromol/L) …I did a quick search that shows higher levels mentioned more, so I'm not sure if this is anything of note; however, I did see some articles about low levels as well.
I haven't received the DEXA bone scan (spine/hip) results yet, but his renal ultrasound continues to look good, which is relieving.
Below are some of the latest blood results:
Total Protein – 8.3 g/dL (6.0 – 8.0 g/dL)
Albumin – 5.0 g/dL (3.6 – 5.1 g/dL)
Alkaline Phosphatase – 240 units/L (130 – 325 units/L)
AST – 41 units/L (10 – 55 units/L)
ALT – 22 units/L (10 – 50 units/L)
Bilirubin, Direct – 4.0 from the last two tests.
Chloride – 104 mEq/L (98 – 106 mEq/L)
CO2 – 26 mEq/L (18 – 31 mEq/L)
Anion Gap – 10 mEq/L (7 – 16 mEq/L)
Calcium – 10.3 mg/dL (8.0 – 11.0 mg/dL) Total calcium has been consistent at 10.3 – 10.2 over multiple tests
Phosphorus – 5.3 mg/dL (4.1 – 5.4 mg/dL)
PTH, 1-84 Bio-Intact – 22.2 pg/mL (10.0 – 65.0 pg/mL) His PTH level decreased to 15 on the last test, however was previously 22/23…I’m interested in learning if rising back to the same level, with slightly increasing ionized calcium is alarming even if PTH levels aren’t high.
Calcium, Ion – 1.36 mmol/L (1.12 – 1.32 mmol/L) This was previously 1.29.
Magnesium – 1.9 mg/dL (1.6 – 2.5 mg/dL)
Vit D, 25-Hydroxy – 42 ng/mL (20 – 80 ng/mL)
Vit D, 1,25-Dihydroxy – 83.5 pg/mL (19.9 – 79.3 pg/mL)
Genetic testing on 35 genes is currently underway as well.
I just wanted to share the latest with you and see if anything stands out.
Thank you again for your reply and insight. It is very appreciated!
Thanks,
Nichole
My apologies, I messed up in pasting some of the results above, starting from the Direct Bilirubin. Below are the additions/corrections:
Bilirubin, Direct – 4.0 from the last two tests.
Hi Nichole, I am not expert enough in liver disease and children to say anything expert about this number. Fred
Hi Nichole, I think the serum calcium ion will not turn our importantly abnormal, and the high 1,25D may be part of genetic hypercalciuria – it is indeed central in it. Above all, he is at a very high quality university hospital with superb expertise, so I am very confident his care will be at the state of the art. What you tell me and what I see are consistent with that idea. I am indeed glad you have found him so excellent a place. Regards, Fred Coe
Hi Dr. Coe,
Thank you again for your responses and your time. Your site has been so helpful in trying to understand what is happening, and I’m so appreciative for all the knowledge you share. And we are blessed he’s at a top facility where we can access excellent care.
I wanted to share an update and would be grateful for any additional insight you may have. With the latest results, I’m even more concerned and confused. I’m still waiting to speak to my son’s doctors, and I’m anxious to find out if these are relatively common findings in cases of his type.
He does indeed have a variant in his ADCY10 gene, which was classified as “unknown significance” because it “is not present in population databases” and “has not been reported in the literature in individuals with ADCY10-related conditions.” I’m not sure if it’s common or not for a variant to be unreported and am curious if this could have some interconnection with other medical issues he has.
Part of the report stated: “ADCY10, Exon 32, c.4625A>G (p.Glu1542Gly), heterozygous, Uncertain Significance. This sequence change replaces glutamic acid with glycine at codon 1542 of the ADCY10 protein (p.Glu1542Gly). The glutamic acid residue is moderately conserved, and there is a moderate physicochemical difference between glutamic acid and glycine.”
His DEXA results also came back. The written report indicates that his spine area is still in the normal range (-1), but his hip area suggests “severe osteopenia.” The report says: “BMD compared to peers of the same age and gender was -1.7 SDS (Z-score) below the mean for age and gender. However, the neck of the hip was -3.3. This study is suggestive of severe osteopenia.”
I am so confused at the moment and pretty alarmed, but not sure if I’m overreacting honestly. So I sincerely appreciate any further insight you may have on the latest results.
Thank you so much again,
Nichole
Hi Nichole, I am afraid I have nothing substantive to offer about these genetic findings. But as your son is at a superb institution I have no doubt among the physicians some will easily interpret them. Regards, Fred Coe
Hello Doctor,
how are you?
I receive my 24 hours urine report today and here are the details:
Summary of Stone Risk Factors
ANALYTE
Urine Volume – (liters/day) 2.45 ltr
SS CaOx – 3.34
Urine Calcium (mg/day) – 66
Urine Oxalate (mg/day) – 67
Urine Citrate (mg/day) – 533
24 Hour Urine pH – 6.406
SS CaP – .37
SS Uric Acid – .22
Urine Uric Acid (g/day) – 552
Interpretation Of Laboratory Results
Hyperoxaluria. Most likely of dietary origin. Bowel disease/surgery and primary hyperoxaluria usually raise
oxalate more than this. Treat with low oxalate diet and diet calcium of 800 to 1200 mg/day. Recheck at 6
weeks.
Borderline high urine pH. High urine pH can promote calcium phosphate stones. When using alkali
supplements (citrate or bicarbonate) manage urine volume and urine calcium to maintain SS CaP less than 2.0.
Stone Risk Factors /Cystine Screening:
Negative (12/09/2019)
Values larger, bolder and more towards red indicate increasing risk for kidney stone formation. See
reverse for further details.
Dietary Factors
Na 24 -156
K 24 – 87
Mg 24 -93
P 24 -.918
Nh4 24 – 30
Cl 24 -177
Sul 24 – 27
UUN 24 – 9.71
PCR.9
Normalized Values:
Cr 24 – 1867
Cr 24/Kg – 23.4
Ca 24/Kg – .8
Ca 24/Cr 24 – 35
I appreciate any insight you may have.
Regards,
Kamal
Hi Kamal, I can try but as you do not say what kind of stones you form what I can say is rather on the abstract side, Your urine calcium is remarkably low, oxalate high, so I think you eat a low calcium diet. The interpretations come from algorithms I wrote when I owned Litholink – the vendor for this urine – and suggest more diet calcium. The SS values are so low that you will not likely form calcium based stones if this one sample represents your average behavior. Frankly I suspect that if you have made calcium stones you did so under different circumstances than now. The higher diet calcium would be good for bone health. Please do not use my comments – ignorant of all clinical details – in treatment, but your physician may be interested in the low calcium as a health issue. Regards, Fred Coe
Hi, I am a 30-year-old male and have a 2mm stone in the mid pole of the right kidney diagnosed a year back with a CT scan result. No other renal or ureteral calculi or hydronephrosis was seen. I have had two previous incidents of stones as a teenager, both of which came out without any invasive procedure. I recently did my 24-hour test. I would love for any feedback you may have. Also, would you suggest any dietary changes? I have been following a very low protein and sodium diet since last year. I really appreciate your time and help.
MinMet Total Volume Ur 3.589 L 2 L
MinMet PH UR 6.58 5.5 – 7.5
MinMet Sodium Ur 24Hr 254 mEq/TV 200 mEq/TV
MinMet Potassium Ur 24Hr 64 mEq/TV mEq/TV
MinMet Uric Acid Ur 772 mg/TV 700 mg/TV
MinMet Creatinine Ur 24Hr 1,660 mg/TV mg/TV
MinMet Calcium Ur 108 mg/TV 250 mg/TV
MinMet Magnesium Ur 24Hr 100 mg/TV 60 mg/TV
MinMet Chloride UR 233 mEq/TV 200 mEq/TV
MinMet Ammonia Ur 25 mEq/TV 45 mEq/TV
MinMet Citric Acid Ur 429 mg/TV 320 mg/TV
MinMet Phosphorus Ur 934 mg/TV 1,100 mg/TV
MinMet Oxalate Ur 37 mg/TV 45 mg/TV
MinMet Sulfate Ur 24Hr 18 mmol/TV 30 mmol/TV
Relative Supersaturation of Calcium Oxalate 0.44 2
Relative Supersaturation of Brushite 0.57 2
Relative Supersaturation of Sodium Urate 1.33 2
Relative Supersaturation of Struvite 0.5 75
Relative Supersaturation of Uric Acid 0.28 2
UREA NITROGEN,U,24HR 8.67 g/TV 7 – 20 g/TV
Thanks!
Shubhodeep
Hi Shubhodeep Paul, Your urine data show high sodium of 254 mEq/day, vs. US tolerable upper limit of 100, low calcium of 108 (I do not understand the 250 mg/d unless there are 2 urine samples or this is some upper limit), your urine citrate is either adequate at 429 mg/d or low at 320 mg/d (Same problem interpreting the data); the SS units are so called relative SS meaning your values compared to a set of normal, an opaque arithmetic developed long ago and no longer much used, but certainly not high. So this brings me to ask what the stones are made of. At first glance I do not much see how calcium oxalate or calcium phosphate crystals will grow in such a medium, but I am unclear about the two numbers for most analytes – duplicate urines, or reference values. If you can clarify things, I will gladly try to do more. Regards, Fred Coe
Hello Doctor,
How are you? Not sure if you received my message earlier. Sending it again. Hope I am lucky this time!
I received my 24 hours urine report today and here are the details:
Summary of Stone Risk Factors
ANALYTE
Urine Volume – (liters/day) 2.45 ltr
SS CaOx – 3.34
Urine Calcium (mg/day) – 66
Urine Oxalate (mg/day) – 67
Urine Citrate (mg/day) – 533
24 Hour Urine pH – 6.406
SS CaP – .37
SS Uric Acid – .22
Urine Uric Acid (g/day) – 552
Interpretation Of Laboratory Results
Hyperoxaluria. Most likely of dietary origin. Bowel disease/surgery and primary hyperoxaluria usually raise
oxalate more than this. Treat with low oxalate diet and diet calcium of 800 to 1200 mg/day. Recheck at 6
weeks.
Borderline high urine pH. High urine pH can promote calcium phosphate stones. When using alkali
supplements (citrate or bicarbonate) manage urine volume and urine calcium to maintain SS CaP less than 2.0.
Stone Risk Factors /Cystine Screening:
Negative (12/09/2019)
Values larger, bolder and more towards red indicate increasing risk for kidney stone formation. See
reverse for further details.
Dietary Factors
Na 24 -156
K 24 – 87
Mg 24 -93
P 24 -.918
Nh4 24 – 30
Cl 24 -177
Sul 24 – 27
UUN 24 – 9.71
PCR.9
Normalized Values:
Cr 24 – 1867
Cr 24/Kg – 23.4
Ca 24/Kg – .8
Ca 24/Cr 24 – 35
I appreciate any insight you may have.
Regards,
Kamal
Hi, I did get the earlier one and answered. Fred
Dr. Coe:
I received the below results and was wondering if you could interpret for me and offer an dietary recommendations?
Thank You very much.
Urine Volume- 1.75
SS CaOX
Hi Michele, The urine volume is low enough to pose an increase of kidney stone formation. SS CaOx is supersaturation with respect to calcium oxalate and is followed by a number that is the ratio of the concentration of the calcium oxalate salt in your urine to its solubility. You do not give a number. Drink more to raise your urine volume above 2.5 l/d, abolishing increased risk from low urine volume. Regards, Fred Coe