My Lab Report

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To me at least, the lovely Blue Door watercolor by Andrew Wyeth is simplicity created by studied art.

Take a look at your lab report(s) and answer these questions. If you have two 24 hour urine collections this time answer from the more abnormal in every case. Here is help for reading these if you are confused. Here is more help.

But keep this in mind. I assume here you have personal physicians; that you have been screened properly to rule our systemic diseases as a cause of your stones; and that your other health issues are being looked after by your physicians. This kind of simplified approach is nice for otherwise healthy idiopathic calcium or uric acid stone formers. Others may need much more.

Section One: Initial Evaluation

Answer the questions.

The blue responses are actions you should take

  1. Is my urine volume less than 2.5 liters?
    1. No – It is high enough
      1. Was my collection representative of my usual life or was I showing off
        1. Representative
        2. Showing off – I should check another urine collected during my usual life
    2. Yes – Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
  2. Is my urine calcium above 200 mg?
    1. No – It is not high enough to increase risk of stones
    2. Yes – It is high enough to increase risk of stones
      1. Is my urine sodium above 100 mEq (1500 mg)
        1. Yes – Lower my sodium intake to below 100 mEq (2300 mg); 1500 mg is ideal
        2. No – My sodium intake is not high
      2. Do I eat a lot of sweets – sugared foods?
        1. Yes – Reduce my sugar intake as it increases urine calcium
        2. No – My sugar intake is not high
      3. Do I eat at least 1000 mg of food calcium daily?
        1. Yes – People with hypercalciuria need diet calcium for their bones – continue this diet
        2. No – I need to eat at least 1000 mg of diet calcium daily
  3. Is my urine oxalate above 35 mg?
    1. No – My urine oxalate is not very high
    2. Yes – My urine oxalate is high enough to increase risk of stones
      1. Reduce high oxalate foods using the lists on this site
      2. I need to eat at least 1000 mg of diet calcium daily
      3. Is my urine oxalate above 80 mg?
        1. No – I can try diet to lower my urine oxalate
        2. Yes – My urine oxalate is so high my physician needs to review the matter and decide what to do
  4. Is my urine citrate below 400 mg?
    1. Yes – It is low enough to raise risk of stones
      1. Is my blood potassium low or do I take diuretics?
        1. Yes – My physician needs to provide potassium supplements
        2. No – Use beverages that provides supplemental alkali to raise my citrate
    2. No – It is not low enough to raise risk of stones
  5. Is my urine pH below 5.5
    1. Yes – My urine pH is low enough to pose a risk for uric acid stones
      1. Is my uric acid supersaturation above 1?
        1. No – Is my urine volume high?
          1. Yes – High volume is protecting me against uric acid stones
          2. No – Uric acid may be crystallizing; Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
        2. Yes – Use beverages that provides supplemental alkali to raise my urine pH
    2. No – My urine pH does not pose a risk of uric acid stones

Select and print this list

Circle the actions you need to do and pin the list up where you will see it

  1. I should check another urine collected during my usual life
  2. Raise my fluid intake to 2.5 liters: 2.5 – my volume = my increase in fluids
  3. Lower my sodium intake to below 100 mEq (2300 mg); 1500 mg is ideal
  4. Reduce my sugar intake as it increases urine calcium
  5. I need to eat at least 1000 mg of diet calcium daily
  6. Reduce high oxalate foods using the lists on this site
  7. My urine oxalate is so high my physician needs to review the matter and decide what to do
  8. My physician needs to provide potassium supplements
  9. Use beverages that provides supplemental alkali to raise my citrate
  10. Use beverages that provides supplemental alkali to raise my urine pH

Get a follow up 24 hour urine test when all of the actions are in play

Section Two: Follow up Evaluations

Here is what to do when you have a follow up test

First answer the questions in Section One.

Then answer the questions here in Section Two

The blue responses are actions you should take

  1. Do I know what my stones have been made of?
    1. Yes – Look at the supersaturation(s) related to your stone(s); call these your relevant supersaturations
    2. No – All three supersaturations may be relevant
  2. Have all of my relevant supersaturations fallen by half?
    1. Yes –
      1. Am I still forming new stones
        1. No – Stay on my treatment and get another follow up in one year; if new stones form get it sooner
        2. Yes – Am I sure this 24 hour urine reflects my usual life?
          1. Yes – I may need medications; see my physician
          2. No – Get another 24 hour urine within the next 6 – 12 weeks
    2. No – Go back over the blue actions in section one
      1. Is my uric acid supersaturation one that has not fallen by half?
        1. Yes
          1. Is either blue action 2 or 10 in section one above suggested?
            1. Yes – Do the blue actions suggested in section one and obtain a new 24 hour urine
            2. No – Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine
        2. No – Either my calcium oxalate or calcium phosphate supersaturation has not fallen
          1. Are any of blue actions 2 – 9 in section one suggested?
            1. Yes – Do the blue actions suggested in section one and obtain a new 24 hour urine
            2. No – Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine

Select and print this list

Circle the actions you need to do and pin the list up where you will see it

  1. Stay on my treatment and get another follow up in one year; if new stones form get it sooner
  2. I may need medications; see my physician
  3. Get another 24 hour urine within the next 6 – 12 weeks
  4. Go back over the blue actions in section one
  5. Do the blue actions suggested in section one and obtain a new 24 hour urine
  6. Raise my fluid intake to 3 liters a day and obtain a new 24 hour urine

94 Responses to “My Lab Report”

  1. SB

    What do you like the oxalate supersaturation to be? The range on my 24 hour urine states <=2.00, is that what you go for under 2 as a goal? Thanks for your time.

    Reply

    • Fredric L Coe, MD

      Hi SB, I am not so stringent. The evidence from the main epidemiological studies would place the risk threshold at around 3.3. IN the article you will find the graph of SS for CaOx shows risk increasing above 1, but that is because the graph uses relative SS, the actual supersaturation divided by the mean value from a group of non stone formers. This group mean was 3.3, so on the graph 1 = 3.3. Confusing? Yes. I wish the group had not used relative SS. Regards, Fred Coe

      Reply

  2. Carol

    Dr Coe, I can not thank you enough for all your information and hard work. One year ago I changed diet for my Phosphate stones (only one removed in ureter 2019) and was able to change my 24 hr urine tremendously. I’ve had 5 done but am going to give you the results of an early one (2019) then one this week after all those changes. Changes-added sugars between 22-25g, Calcium 800mg (Endo doc said to keep around here), Protein 60g which is from very little animal meat, get from dairy, fruit/vegs, breads and my sodium intake around 1100-1200mg/day plus 15-16 cups of water a day. I have around 9 fruits and vegs a day and realize my citrate is low but believe it comes with CaPhos stone history and what goes along with that. Thankfully with all those fruits/vegs I added my urine PH stays around 7 and does not go higher. The first number being the older and 2nd being this week.
    Uro Calcium 324-204
    Uro Oxalate 23-29
    Uro Uric Acid 513-360
    Uro Citrate 350-341
    Uro PH 6.9-7
    Uro Volume 2.73-4.14
    Uro sodium 95-44
    Uro Phos 871-584
    Uro Mag 87-81
    Uro Ox Sat 1.33-.92
    Uro Brus Sat 4.39-1.52
    Uro Sod Ur Sat .62-.10
    Uro Potassium 48-45
    Uro Creatine 1054-742
    I do know that Calcium needs to be below 200 and Brush Sat below 1 but I think this is all I can do myself. Based on what I read my Creatine is fine because the low range said 600 and I had weight loss from the changes so I’m 49kg and from research I did they go by 15-20mg per kg of body weight. I’m just assuming but I think these changes would be fine without meds “if” I’m not forming new stones or the ones I have are not growing but the problem is they only order Kidney US because they don’t want to do CT’s yearly so it will be hard to tell. Based on US the last couple years I have one stone in each Kidney each between 3-5mm but last CT from 2018 shows multiple scattered stones up to 2.7mm in one kidney. Having new US tomorrow and seeing Urologist next week and I know for certain with the changes he will not want to put me on Thiazide, even when my numbers were high he would say I don’t want the side effects that you can get from them even though I see you’ve written it’s tolerated well. As of now my Endocrinologist says I don’t have PHPT. I had questionable numbers but she asked me to go to a better lab and as said on your website I did the test fasting early morning which wasn’t always done in the past because they said it didn’t matter……I knew better! Each time at new lab and fasting the number were normal. Again I just wanted to thank you for all the info about what to do for my CaPhos stones on your site.

    Reply

    • Fredric L Coe, MD

      Hi Carol, You are a very capable administrator of your own care, and I am happy for you. I do look with disfavor on the CaP SS over 1, and hope you will lower it more. Urine sodium seems quite low, volume high, so the residual SS is arising from the pH (7) and low citrate. Let’s hope new stone rate falls to 0. I do not like US for stone counting and mention that modern CT scanners can bring the radiation dose to very low levels. Counts are crucial. Regards, Fred Coe

      Reply

      • Carol

        Dr. Coe, I fully agree with you and saw my urologist and he refused me the CT even after I explained that it is low dose and necessary to count. I’m in my 50’s so it’s not like I’m very young for extra radiation. Also he does not believe I need meds because my values are in the normal range for the lab. The range for the PH is 5.5-7 and of course mine is high at 7 and the Brus Sat range is <=2.00 and mine is 1.52. The endocrinologist said she wants to leave it up to the urologist on taking meds. I can not go to another group of endo/uro because I work for this hospital and we have their insurance. Is there anything else I can do on my own that you can think of to lower those numbers? Again thank you so much!

        Reply

        • Fredric L Coe, MD

          Hi Carol, Frankly I cannot quite figure out how to help you. Perhaps your hospital would let you seek a telehealth consult with me at University of Chicago. It should not be too costly (as a professor I really do not know how billing for my time works). Your physicians might be interested in what I had to say. If you can, my secretary is at 773 702 1475 (Banita Williams). Regards, Fred

          Reply

          • Carol

            Dr. Coe, I’m considering a virtual visit with you as you stated above but seeing if it’s feasible since my insurance will not cover you being fully out of network. They don’t allow a contractual adjustment/allowed amount for out of network services. I spoke with your financial dept about the cost of the visit and it’s over $700. In the meantime while I decide is there any way for me on my own to increase my urine citrate without raising my PH? Again because my physicians believe my numbers are in normal range including my citrate of 341 with the lab range of >= to 320 they won’t put me on thiazides for prevention. Like you mentioned I need to get my Brus SS even lower which I got down to 1.52 from 4.39 as I stated in the original email above to you. I do have urine PH strips I use to monitor and with all the fruits and veggies I added with my changes, 9 a day luckily my PH stays at 7 no matter how many I eat. They will only order a yearly 24 hour urine. I tried on my own to get a nephrologist appt. for prevention but they stated I needed to have a referral from one of my doctors and since my doctors think all my labs are normal I don’t need to go to nephrology. Thanks again for your advice.

            Reply

            • Fredric L Coe, MD

              Hi Carol, You do have an issue. Your urine citrate is low enough to confer stone risk, and probably reflects more complex problems that cause it. But I do not know how to help. Perhaps there are university physicians who are in your insurance network – I would try that route. Regards, Fred

              Reply

  3. Lisa

    Dr Coe,
    Do Vitamin D supplements alone, not with Calcium added cause increased Calcium in the urine and if so what amount of Vit. D would cause this? If it does cause more Calcium in the urine is it because Vit. D helps the body to absorb more of the Calcium we eat?

    Reply

    • Fredric L Coe, MD

      Hi Lisa, Just 25D is not known to increase stones. If your 25D is low, I suspect bringing your levels to normal will raise urine calcium, but in the normal range I do not believe urine calcium will much change. Vitamin D is important in calcium absorption, as you say. Regards, Fred Coe

      Reply

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