Jill Harris has contributed many articles on diet to this site. Here she uses her vast experience from Litholink and her practice to offer help with one of the more onerous aspects of kidney stone prevention. Fred Coe
Why
You have a kidney stone episode and your doctor asks you to collect your urine for 24 hours. Why oh why is this being asked of you? Isn’t it dreadful enough that you just had a kidney stone?
The only way to find out WHY you are forming kidney stones is to complete a urine collection.
The test results will tell your doctor how saturated your urine is with stone making crystals.
The more saturated your urine is, the more likely you are to form new stones.
Some clients have come to me and said, “Why do I need to do a urine collection if the doctor removed my stone and had it analyzed?”
A stone analysis may tell you what type of stone you made, but there are many different reasons you may have made that type of stone.
Figuring out your prevention plan is very complicated, and without a urine collection it is nearly impossible.
>One Day or Two Day Collections?
When you do your first collections, the ones your treatment is going to be based on, it is wise to do two: Two 24 hour urine collections.
Before you start pulling your hair out, let me tell you why.
What you eat and drink during your collection is going to be represented by your test results. If you do your collection on your birthday, you may be celebrating, drinking, eating foods you don’t usually eat and this will not represent a “normal” day for you.
If you do two collections, your test results will show a better picture of what you are eating and drinking.
Sometimes I see a two day collection and the day to day results are so very different they enable me to ask some important questions. For example, “The sodium levels in your urine were very high on your first collection, did you go out to eat that day?”
When I worked at Litholink Corporation we would tell patients to collect their urine on a weekday and a weekend day.
We requested the collection be completed this way because typically what we eat during the week is not what we eat during the weekend.
This way the lab results would show the difference between eating and drinking habits and we could offer better treatment suggestions to the doctors on the lab report.
How
Always Drink and Eat Normally
Many patients don’t want to hear their doctor scold them for not drinking enough so when they do their urine collection they drink and drink and drink. This is not what they usually do. Some already know they were eating badly and made some big changes so their tests would look better.
Why am I going to call you out on this? Am I just a pain in the neck?
No.
Cheating on Your Collection Days Will Not Help
If you drink more than you usually do or eat differently than you usually do, your doctor will base your treatment plan on what you did for those days.
You want your treatment plan to be based on what you usually did when you formed stones so that changes you make will lessen your chances of making more stones.
Suppose you already know you should drink more water, and you do it during your collections. You never did it before, when your stones were forming. Your doctor sees that you’re drinking 4 liters of water a day (you wanted to impress him or her).
S/he will be impressed and assume that low fluids were not and will not be your problem.
But, maybe low fluids were your problem. You won’t know and neither will your doctor.
So what?
No one, including you, will make fluids a priority and you may well forget to keep showing off.
Then what?
Maybe nothing else was wrong except low fluids, and that was gone for the moment – when you did the tests.
Maybe the fluids have already fallen back to your original low levels.
Your doctor will not be able to offer you any help, or worse, may tell you something generic like “avoid all green, leafy vegetables”. I don’t want anyone avoiding green, leafy, veggies if they don’t have to.
I tell clients, “if you drink gin all day then please do that during the test”.
If you don’t drink much water, please do as you normally do.
Getting on the right treatment plan is imperative in preventing new stones from forming. The only way to get on the right treatment plan is to eat and drink as you normally do on the days you are collecting your urine.
Period.
Diet Changes Before Collection Begins
Some of you were told to change your diets before doing the urine collection and wind up doing the collection while on your new diet.
This will NOT help.
You want your results to show what you did while you were making stones. For the day(s) you are asked to collect your urine, eat as you did before you knew you had a kidney stone.
Then go back to doing what your doctor told you to do or what s/he tells you to do after the test results are available.
Don’t Collect During Holidays
Many people will want to do their collection on the holiday because they are off work. If you are like me, you eat differently on holidays than you do on non-holidays.
Thanksgiving is not representative of how you normally eat, so this is not the time to do your collection.
Remember, since your results will show what you ate for that particular day, a treatment plan based on holidays will not be useful to you. Your doctor may tell you to go on certain diets that you do NOT have to go on.
That would not be helpful at all!
Make Time to do the Urine Collections
I completely understand that doing a urine collection is a total pain in the neck. It is annoying and nothing you want to do.
BUT.
There is nothing quite as bad as having a stone attack. If you have to weigh one against the other, doing a urine collection is the clear winner.
Find the time. It’s worth it.
Occupation Need Not be a Barrier
I have had pilots, truck drivers, surgeons, salespeople, and teachers all find the time and make collections while at work. Whether or not it is possible depends on a lot of circumstances, but doing it on the job is the ideal for one of your two days.
Some of you will not be able to bring the collection jug to work.
Perhaps you might have to take a day off from work.
If you do take a day off from work, please drink and eat as you normally would on a work day.
If you do a two-day collection, remember to do one on a weekend so your doctor can see how it differs from a weekday.
Questions About Your Collection
Once you receive your urine collection, please read all instructions on how to complete it.
If you have any questions, call the place of business you received your supplies from and ask them all the questions you may have before starting the collection.
It is dreadful when you have to re-do a collection because you didn’t do it the way they wanted you to.
Follow-up Collections
Once you do your initial 48-hour urine collection, the doctor will go over the results with you.
From those results, you will be told to do certain things that will help prevent stones in the future. You may be told to go on medications, drink more water, change your diet, or all three.
Four to six weeks after you have incorporated all the changes your doctor has prescribed for you, your doctor SHOULD ask you to do a 24-hour urine collection to make sure those changes are working for you.
If you don’t do a follow-up, how will you know if your treatment plan is working?
If your doctor doesn’t order a follow-up, ask for it.
You should expect your doctor will contact you about your results and make whatever changes are needed to get you the best possible prevention.
Annual 24-Hour Collections
Our urine chemistries change over time. It is prudent that you complete a yearly collection to ensure your treatment plan is still working for you.
Partly urine chemistries change because we are getting older, or have developed some new disease condition.
Diets change even if we are unaware of the changes because they occur slowly.
We gain or lose weight which can affect urine chemistries.
Our habits change: We give up or get a health club membership, or start running.
A Final Thought from Jill
Clearly now, you can see how important it is to complete urine collections.
I want you to know that I don’t ask you to see the importance of doing these darn collections without having compassion and empathy that you have to do them.
I know they are not convenient, nor are they fun.
Just keep in mind that if you don’t complete a urine collection, you will not know why you formed stones and will most likely keep right on forming them. I want to keep you away from that scenario.
Prevention is always our best defense. Completing your collections is a pretty benign way to keep stones at bay.
I have staff and Mercer in my blood from a fall had to have back surgery from that almost died I also have kidney stones in both kidneys right now the dr said my body just makes them some time they get stuck and I’m in the er are having surgery the dr is doing a 24 hr urine if my body is making these no matter what I eat are drink why would the dr need a 24 hr urine
Hi John, you have two apparently separate problems – infection from back surgery and bilateral stones. I can see why your physician wants to prevent more stones, and how stones and your back infection might interact poorly. The blood borne infection could infect the stones you have, and any obstruction of a kidney by a stone might lead to kidney infection from the bacteria in your blood from your back. So any amount of effort your physicians put forward is of great value here. The 24 hour collection is essential, and the article you posted on has a lot of the reasons. It would be easiest to begin by just reading it in detail – I know I am not the easiest writer to read and apologize in advance. Your physicians seem to be doing a fine job and have their hands full. Regards, Fred Coe
I am just about finished a 24 hour collection that I have done perfectly, and took the day off work to do… by sheer (bad) luck, I checked the clinic hours where I need to drop it off tomorrow and they have a “scheduled closure” all day. Can I finish this sample and just keep it in the fridge to submit a day later? I don’t think my boss is going to be happy with another day off for this… when I already know I will have to so two more of these tests… Thanks for your advice.
Hi A,
Best to call the lab that the testing kit came from to find out next steps.
Good Luck, Jill
Hi A, putting a 24 hour urine in the fridge is not a good idea. I would finish it, room temperature, and bring it in a day later. Regards, Fred Coe
I was told to keep the jug in the fridge the whole time. Confused now
I am using supplements, do I need to stop using them for urine collection?
Hi Huy,
If your doc has prescribed the supplements continue. If you are taking them on your own accord, please stop 5 days and during the collection.
Best, Jill
My lab insists on my patients doing a separate acidified urine collection for oxalate determinations. Doing 2-24 hr collections unfortunately deters many patients from being assessed. I have found a few papers showing that urine calciums do not require collection of urine in acid. I have been unsuccessful in finding a reference paper to support the use of one urine collection, which can be acidified at the lab after the patient brings it in. Any thoughts?
Hi Doctor, Litholink does ideal 24 hour urines with one collection. Using acid for oxalate is an old fashion long ago dismissed as unnecessary. I mention Litholink because I founded it, know how their methods work, and am free to recommend it as I sold it years ago to LabCorp and have no financial relationships of any kind with it or its parent company. We studied all this business of acid, recovery of oxalate, and found a single urine does it all. By now Litholink has done over a million or more such urines. Drop the lab you are using or get them into the modern world. Fred
Was so happy to find that site! I need help. I was diagnosed with MSK in 2017. Past years I had 1x/2x a year pain. Last week I had a bad flank pain which brought me to the the Primary Care Center. They found 1 kidney stone right side and reconfirmed a previously diagnosis of MSK in 2016. Doc wants me to do a routine urinalysis. I’d like to request for 24-hour urine test. What kind of 24H urine test should I request? I called a local lab and they told me there are diff types of 24H urine test (protein, creatine, etc).
Hi Joy, as I wrote in my first response to you, I found out last fall that Philippines lack 24 hour urine testing as needed for stones. I urged several influential people there to organize a national testing lab and believe that some efforts are underway, but so far as I know that has not as yet happened. It is impossible to improvise testing, it requires a special lab to get it right. Routine urinalysis is not itself helpful for stone prevention. Regards, Fred
i am 68yrs old and about to order a 24hr urine collection. I have a kidney stone in the upper lobe. My dr won’t arrange this for me, he says 80% are oxalate and to cut back on salt, sugar and drink plenty….but i want to know what’s going on and how to slow them from growing and to make a ”correct” informed decision on a diet plan for the specific type of stone…..do you have any suggestions please for what i ask for when picking up this 24hr collection kit. thank you very much for you time.
Hi Linda, You are best off using a commercial kidney stone urine vendor, Litholink is the best of these. If your urine testing is not done by a vendor I am afraid quality will be variable. I would specifically ask your urologist or PCP to order a Litholink 24 hour urine. They provide collection and mailback materials, and superb instructions and reporting otherwise unavailable. ALthough I founded Litholink I sold it to Labcorp in 2006 and have no financial ties to it or Labcorp. Regards, Fred Coe
Actually Jill i find your comment on the enjoyment of the Piss Jug to be quite wrong, i infact enjoy it so much
Doctor – I am Arun from India. I have kidney stone from 2017. Never done surgery because of fear. I tried lot of medicine for dissolving stones. Homio , Ayurvedic , Herbal etc. but no result. I dont have any pain. My uric acid level was high and on general scan I came to know that I have kidney stone. Last week I done Ultra sound scan again now its size increased to 10mm, 5.5mm. and 4.5mm.
I told my Doctor about your suggestion on 24hours urine test. But he is not agreeing. He is telling me to do the surgery first then we will send the stone to lab and then will identify what type of stone I have.
Doctor, could you please tell me on 24 hours urine test what all details I have to test? I went to lab and they asked me what all test is required with 24hours urine test. I told to identify kidney stone causing issue and they told they dont know that. Check with doctor and give the list what all test need to be done with 24hours urine.
So could you please give me the list of test that needs to be done with 24 hours urine.
Thanks In Advance.
God Bless you and family!
Hi Arun, I believe in general Indian stone prevention has lagged a bit behind Europe and US. Analysis of the stone is very important but so is 24 hour urine testing. Here is the usual list of what we do in 24 hour urine studies. Regards, Fred Coe
I am thrilled that you are here to help.
My son has advanced primary progressive MS. He has a suprapubic catheter. After he started OCREVUS he developed one kidney infection and huge stones after another in one year. He never had stones before even with the catheter for 9 years.
So, now we have the kit to do 2-24 hour collections. I only have one concern about his collections. I called the 800 number, but, they had no idea other than stick the catheter in the jug…not a good idea as he spams frequently. The preservative bottle is too big to get into a urine bag.
My concern is if I clamp his cath he will leak out the normal way and have more spasms. I will not be able to collect every drop. And I won’t get sleep having to drain him every few hours. (I will do what needs to be done.) He cannot do this himself.
My current plan is to change his catheter the day before we start. When we start the tests I will put a clean bag on and drain it every hour or two. I may clamp for short times.
My concern is does bacterial growth matter with this test? I can’t put the preservative in the bag. Can I put his collection bag in a tub of ice? ( I know I do not refrigerate.) Or do I just collect an empty at what time periods?
I am a retired RN so I feel confident about everything else that needs to be done.
Today is 4/28 and I plan on starting on 5/1/21 to coordinate with Fed delivery within 96 hours from Iowa to Ill.
Thank so much for your help.
Malika
Hi Malika, Your plan looks fine. The collection system contains powerful antibacterial materials – if it is Litholink Corp -. You do not say what the stones are, are they from infection – struvite (magnesium ammonium phosphate??). If so, treatment is not so much from 24 hour urine data as it is about the bacteria. Regards, Fred Coe
Hi Dr. I passed an oxalate 3mm stone 2.5 yrs ago. A CT scan shows another 3mm stone. Should I take the 24 urine test or since I know what I passed in the past I can assume it is oxalate? Also… how much water should I actually be consuming… I read for oxalate stones to drink 3 liters (110 ounces)… I average about 60 ounces. Should I up my consumption??? Thank you!
Hi Robin, The fact that the stone was calcium oxalate does not imply high urine oxalate is important. Here is a nice review about common calcium oxalate stones. Water is always a good idea, the article tells about other valuables. Regards, Fred Coe
I am a Pathologist having own laboratory exclusively for Urinary Stone disease evaluation. I am doing 24 hrs Urine Metabolic test with Super-saturation. I want to know , can we opt for State (single sample) Urine Metabolic profile in stead of 24 hrs collection? Has any done comparative study about that ?
I am asking this because many clinicians wants to get Urine Metabolic test on single (state) collection because many patients do not turn out for 24 hrs collection. Thanks
Hello Dr Mehta, In our CRC research we find urine calcium, oxalate, pH, volume, supersaturations – more or less everything – change over the day and especially overnight. So I think a single sample is not a good idea. It costs as much to make the measurements, and the results will not represent the average for a 24 hour day but only some random part of it – very misleading. I am against the idea with all my heart. Best, Fred
I am investigating how a 24 urine sample could be affected if not kept in Ice or refrigerated during collection could you explain to me? I am a nurse Thanks in advance
Hi Damaris,
If the urine has a proper preservative, refrigeration is not needed. Litholink is the only national vendor that has exact methods for the collection and analysis and I would recommend using it for your patients. I founded LL in 1995 and sold it to Labcorp in 2006 so have no financial relationship to the company. Regards, Fred
I am a U of C patient and received the collection containers and will complete my collection. I need the instructions for collection and drop off. It was 3 or 4 sheets and i cant find it. can you email it to me? rmchugh4@yahoo.com my number is 312 399 8270 birthdate 11/27/1973
Hi Robert, I will see to this, and hope it has already been taken care of. Fred
Good advice! I understand that there is a sample email to send to the urologist requesting (demanding?) the 24 hour urine test(s). Please advise.
Patrick
Hi Patrick,
There is no sample email but you can simply ask your doc to order you (any doc can order it) a 24 hour urine collection panel for kidney stone risk. IF they say no, tell them you want it because you want to know why you are forming stones so you can get on a treatment plan to stop forming stones.
jill
Good advice! Where do I find sample email to request 24 hour urinalysis to my urologist?
Thanks,
Patrick
Having PCNL surgery in two weeks. Should the urine test be done before or after or does it matter?
Hi Liz S, I matters. Before may be faulty if there is obstruction, so not ideal. After may be faulty if you are not back on your normal diet and doing your normal work, so wait until both are true. Regards, Fred Coe
Dr. Coe, Is there a site where I can obtain a 24 hr urine as needed? I an 69. I have had three 24 hour urine studies, two a year ago, and one in Nov. I had incidental 3 stones noted on CT(for abd pain), largest 4mm. Based on the first two studies, dietary correction was deemed adequate with decreased Ox., although Ca24 was still elevated at 345. My urologist (atonic bladder)felt nothing more need be done since stone load unchanged( second CT for SBO) I kept the nephrology appt which was 10 months later. The third study this Nov showed SS CaOx 6.10, Ca24 of 609!, Ox24, Cit24 1207, SSCaP 2.53, pH 6.1,. Dietary: Na24 126, K24 57, Mg24 229, P 24 1.092, Nh4 24 61, Cl 24 148, Sul 24 UUN24 44, PCR 1.3 … It was felt to be hereditary IH and not dietary therefore was started on 25mg Chlorothalodone. I am just taking 12.5mg currently until side effects (dizziness) diminish, but after reading your articles realized that 2 days before I took the test, I had a sugar blowout, and wonder if these results are the result of that. I don’t want to take more RX if it is not needed, and I also have to cath due to atonic bladder, l drink 64oz /day and do low carb /moderate protein (80gm) so my sodium is already lower. I am not scheduled until Dec 2023 to see the Nephrologist. Repeat urine is not for 6 months. Have also tried to schedule with your office, but no result yet. I several other health issues that complicate the matter included hx of SBO, ongoing intermittent ab pain, with abnormal Small Bowel (undiagnosed) that I am still waiting to be seen for as well as a neurologic dx with complications. Both the gut and neurological issues may require surgery. I would like to check results sooner while I am still on the 12.5 mg , then again as things change. I am in the medical field and in the short term could make some headway on my own for now.
Thank you,
M
Hi Margaret, It is a very complex problem. If you had chosen a telehealth visit here, there is no reason against it. My secretary is at 773 702 1475 and you should call and remind her to take care of the matter. Regards, Fred Coe
Iam very glad to read the findibg you have given.. Thank you so much Sir.My husband has kidney stone disease. He is 40 year old obez, diabetic man with family history of kidney stones, He used to get 3-4 stones in a year. Stone analysis done once showed calcium oxalate stones.24 hour urin analysis done once showed normal results. ( test conditions were not according to what you have suggested )Since one and half years he is following low carb moderate protein healthy plant based diet. He didnt loose any single kg weight. But since 1and half years he didnt have any stone. But in december 2022,he got stone pain and both ureter got blocked ended up in URS procedure and stent etc. CT repirt showed multiple stones largest was 9mm. Now my dout is when can l ask for a 24 hour urin analysis, since he is admitted in hospital for stent removal and one stone removal now.hope you will answer my question.
Hi Dhanya, Most important is the analysis of the stone. Is it uric acid, calcium oxalate, calcium phosphate?? Everything hinges on that. 24 hour urine testing is not best done when stents are in place but when they are gone and he is eating normally. Regards, Fred Coe
My husband is a U of C patient and was given an order by his Dr. to complete a 24-hour urine collection. We were able to print out the order from My Chart but did not receive instructions on where to go for pick-up/drop-off or how to go about this. Any guidance on next steps?
Hi Laura, I copied this to our clinical secretary and I have asked her to fix whatever problems your husband has encountered. I apologize. Regards, Fred Coe
what is the self pay cost for the study from Litholink:
My kit from Litholink came with two jugs and two vials but only one return shipment box. It also says to ship back same or next day. If I do two runs, then the first run will not ship back “same or next day”. Please advise
Hi Franzi, One needs to call Litholink and let them figure this one out. Fred
I passed a stone in September 2022.
I had a 7 mm stone stuck in my ureter in October 2023
I had lithotripsy with stone removal on November 7 2023, there were multiple smaller stones in that same kidney that were also removed.
I was told that I have multiple stones, including another 7 mm stone in my other kidney. My nephrologist doesn’t feel surgery is needed as the large stone is in the lower pole. I am waiting on an appointment with my urologist to get his opinion, I don’t have an appointment until April 2024.
I had a 48 hour urine test through Litholink in February 2023, after having blood in my urine so the test was not done around the time that I was having kidney stone pain.
Urine calcium 116
Urine oxalate, 34
Urine citrate, 1113
SS CaOx 7.49
SS CaP 1.51
SS Uric acid .99
Urine pH 6.084
Urine Uric acid.580
Urine volume .98
I have been on a low oxalate diet for about 2 to 3 weeks and increasing my daily intake of water to 2.5 L. My question is, should I be having another 24 or 48 hour urine test now?
Hi Sheila, Am I mistaken or do you report a remarkably low daily urine volume of 0.98 l/d? That alone is a powerful risk factor for stones and rather eye opening. By this time I would have thought your urine volume would have been greatly increased – by you, and because of your physicians. There are no abnormalities in your urine that would cause stones if your urine volume were 2 liters/d or more. The low flow patients are like you and often unaware of their remarkably low fluid intakes. Whatever you do correct this promptly as best you can. Regards, Fred Coe
Hello, Dr! A cat scan detected that I have a few small calculus in my kidney tissue. My doctor asked for a 24h urine oxalate. Is this the best 24h urine test to figure out what’s going on? Can the 24h test measure more than one thing at a time? F.i. Oxalate, calcium etc. thank you!
Hi Malena, It is best to do a comprehensive collection. Here is a good beginning point for a proper evaluation. Regards, Fred Coe
Thank you!
I had my first Litholink test done in January after a lithotripsy in December on my left kidney. On April 5, I had my second lithotripsy on my right kidney. I started on a low oxalate diet including increased hydration in January. I recently had a KUB X-ray before my urology follow-up visit. How soon should I get this Litholink test done after this second lithotripsy. I feel that I should do it before I see the urologist at the end of this month.
I already have the collection container with a Dr. order for the test, so I am ready to start anytime.
Thanks!
Hi Ken, it needs to be before the visit but also needs to be when you are back to your normal diet and level of activity. All that is your judgement of the conditions. It is one frame out of a movie, 365 frames a year. The stone analysis is crucial, be sure you get it. Best, Fred Coe