HOW TO READ YOUR KIDNEY STONE LAB REPORT – Calcium stones

IMG_2303Jeff, 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 hypercalciuriaThe 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.

 

213 Responses to “HOW TO READ YOUR KIDNEY STONE LAB REPORT – Calcium stones”

  1. MichaelM

    Dr. Coe:
    I recently had a LithoLink 48 hour study done with the following (partial) results:
    Calcium Oxalate 27, 26
    Volume 2240, 2100
    Calcium Oxalate Saturation 3.34, 3.61
    The ranking scale that my health system portal attached to that last result ranking it as “low”, but elsewhere you have written that a saturation above 1 is high and a risk factor. Is Litholink calculating this saturation in a different way than you do, or is the health system ranking incorrect in your judgment?

    Reply
    • Fredric L Coe, MD

      Hi Michael M, I think ‘Calcium Oxalate’ looks like 24 hour oxalate, and is normal. The SS values for CaOx are not very high. The one that needs to be below 1 is for calcium phosphate (CaP). The Litholink analysis was written by me when I owned the company, and I have no idea how a health system could possible make up its own scales. I hope this does answer your question but you do not post the CaP SS so I cannot be sure. Regards, Fred

      Reply
  2. Claire M

    Hi Dr. Coe,
    After seeing your website I was very interested as well as the professionalism you show by responding. I know this is not for medical advice (but it would be nice to see another opinion) I’ll give a little background: first stone attack at 12 & hospitalized, lithrotripsy at 18, in and out of urgent care due to frequent UTIs and stone attacks. I have about 6 UTIs a year. I have bilateral stones. I have uteroscopy scheduled for the removal of the seven stones currently residing in my left and right kidneys next year. I am currently seeing multiple doctors to figure out if it is a genetic condition. I have been struggling with this for 13 years now! (I’m a 25 yr old female)
    Here is my most recent 24 HR test
    24 hr Uric Acid .547 g/d
    Urine pH: 6.415
    24 hr Oxlate: 16 mg/d
    24 hr Citrate: 242 mg/d
    24 hr Calcium: 217 mg/d
    Urine Volume 1.64 L/d
    Supersaturation CaOx: 4.31
    Supersaturation CaP: 2.44
    24 HR Creatinine: 1,290 mg/d
    Creatinine per body weight kg: 17.9 mg/d/kg
    24 hr Calcium per Kilogram Body Weight 3.0 mg/d/kg
    24 hr Calcium per 24 hr Creatinine 168 mg/g
    24 hr Sulfate 23 mEq/d
    24 hr Chloride: 74 mmol/d
    24 hr Ammonium 27 mmol/d
    24 hr Potassium 31 mmol/d
    24 hr Sodium 85 mmol/d
    24 hr Phosphorus 0.837 g/d
    24 hr Urea Nitrogen 7.54 g/d
    24 hr Magnesium 82 mg/d
    Protein Catabolic Rate 0.8 g/kg/d

    Reply
    • Fredric L Coe, MD

      Hi Claire M, Your urine is like that of a calcium phosphate stone former, with its high CaP SS and ammonia excretion exceeding sulfate. Your urine calcium is a bit high, volume low. It is the low citrate that makes your physicians concerned about genes, and I suspect it is indeed inherited, but that is nothing much for clinical practice. Frankly to me you seem rather routine. I do note the low urine potassium, making me wonder about prior diuretics, or acid blockers, or diet issues. Of course this is not a medical opinion, as I do not even know your stone type – by now it might be struvite, with all the infections, or brushite – a special kind of problem. Regards, Fred Coe

      Reply
  3. Nicole McGalla

    Hi Dr. Coe,
    I just had a urine test done. My first test 6 months ago and this test varied widely with regards to phosphorous and sulfate. I don’t eat tons of meat, but I greatly increased calcium intake to offset high oxalates in my test 6 months ago so that may be the result of more protein intake. Should I be concerned?
    Phosphorus, 24 HR ur went from 468.6 to 1779.7
    Sulfate, 24 HR ur went from 17 to 56
    Calcium went from 112 to 344
    Oxalates fell from 73 to 19
    Citrate still low from 97 to 98
    Full results:
    Total Volume, Ur 3700 mL/24 hr
    Total Volume: 3700 mL
    Preserved Urine Volume 3700 mL/24 hr
    Ammonia, Urine 33360 ug/dL
    Ammonia, 24HR Ur 72 mEq/24 hr
    Calcium, Ur 9.3 mg/dL
    Calcium 24HR Ur 344.1 mg/24 hr
    Citrate, Ur 97 mg/L
    Citrate 24H UR 359 mg/24 hr
    Chloride, Ur 25 mmol/L
    Chloride 24HR Ur 93 mmol/24 hr
    Creatinine, Ur 29.7 mg/dL
    Creatinine,Ur 24hr 1098.9 mg/24 hr
    Cystine, Quan. Urine 6.41 mg/L
    Cystine, Quant, Ur, 24hr 23.72 mg/24 hr
    Magnesium, Ur 3.9 mg/dL
    Magnesium, 24H Ur 144 mg/24 hr
    Oxalate, Ur 5 mg/L
    Oxalate, 24HR Ur 19 mg/24 hr
    Osmolality, Ur 324 mOsmol/kg
    pH, 24 Hr Urine 5.3
    Phosphorus, Ur 48.1 mg/dL
    Phosphorus, 24HR Ur 1779.7 mg/24 hr
    Potassium, Ur 18.4 mmol/L
    Potassium, 24HR Ur 68.1 mmol/24 hr
    Sodium, Ur 26 mmol/L
    Sodium, 24HR Ur 96 mmol/24 hr
    Sulfate, Ur, mEq/L 15 mEq/L
    Sulfate, 24H Ur 56 mEq/24 hr
    Uric Acid, Ur 9.2 mg/dL
    Uric Acid, 24HR Ur 340 mg/24 hr
    Brushite 0.31 ratio
    Calcium Oxalate 1.92 ratio
    Monosodium Urate 0.14 ratio
    Struvite 0.01 ratio
    Uric Acid 1.10 ratio

    Thank you for looking at this!
    -Nicole

    Reply
    • Fredric L Coe, MD

      Hi Nicole, You increased your protein load about double. This raised your urine calcium, sulfate, ammonia, and lowered pH, and no doubt your increased diet calcium raised your urine calcium as well. Because oxalate fell so low SS CaOx is trivial and because the pH is so low CaP SS is very low. Perhaps you may have overdone things just a bit on the protein intake – I do not see a PCR value but it should be there and should be around 1.0. Urine phosphate is simply from diet, and more protein and milk more phosphate – it is not a stone risk. Of course, I do not know your medical situation, so these comments are for you AND your physician, who is in charge. Regards, Fred Coe

      Reply
  4. Christine Davis

    Hello Dr. Coe, I was to see you soon but your appointments have just been pushed back. I was hoping you may answer here if I can do things to help myself feel better sooner. I’m supposing calcium and/or magnesium citrate could help but I’ve tried various supplements over the last 9 months and have just you’d so I am anxious. I am in so much discomfort and pain, mostly in my body vs kidney’s, ie; joints, muscles, inflammation and disrupted sleep, so I am wanting to lay down most of the time. My pain Dr. Doesn’t understand how bad I feel and is pushing me as to why I am bedridden and not going to physical therapy.
    I was on miralax over 10 years and have suffered greatly but I am gracious to God that he allowed wisdom to point me in the right direction. I am about 9 months post discontinuation of miralax and also a low oxalate diet.
    My results that stick out are:
    Ss caox 14.40
    Ph urine 6.78
    SS Cap 1.91
    Yes, my urine output is low, I will try to drink more, I dont know why I cant.

    Dietary factors
    Pcr 0.6

    Blood
    Phosphorus 4.6
    Co2 32, I was diagnosed as cough variant asthma, I deduced that this is oxalate related since burning of plant matter, wood, triggers the persistent cough for almost a week and from input from oxalate/autism researcher, Susan Owens and support group for oxalate sufferers.
    Thank you greatly, Christine

    Reply
    • Fredric L Coe, MD

      Hi Christine, I am sorry about the wait – Of all you have said, with respect to any urinary symptoms the most important matter is your urine volume. Otherwise, we should wait until I can visit with you and review all of your details. Regards, Fred Coe

      Reply
      • Maria

        Hello Dr. ,
        My name is Maria. From last two months I m having severe back pain+ front and Hip area pain, vomit, fever, incomplete urination + frequent, sleepless. Recently I have blood test which shows epithelial cells, protein trace, CA oxalatr crystal, blood, pus cell2-4,red blood cells.
        Urine appearance is yellow, PH 5, turbid, 30ml , specific gravity is quite high.
        Leukocyte count is high, platelet count is at lower side.
        X-ray is clear

        Kindly suggest me what to do.

        Reply
        • Fredric L Coe, MD

          Hi Maria, It seems likely you have urinary infection, at least as a possibility, and your physicians need to evaluate it. The crystals can form in a highly concentrated urine, as this one was – high specific gravity. Much higher fluid intake should make an end of the crystals, and since your x ray is negative and you have no stone passage history I would not think more needs be done about stones. However if there is no stone, and if your urine continues to show blood or white cells, a CT scan would be more definitive for stones or other causes. Of course, this is mere outsider suggestions, your personal physicians are responsible for your care and may think otherwise, for good reasons. Regards, Fred Coe

          Reply

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