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. GF

    Hello Dr Coe,
    I’m wondering if there is a difference in the type of calcium in the diet that would cause more to spill into the urine. I’m not talking about supplements but between dairy products vs other foods that have calcium like breads, fruits/vegs, etc that isn’t dairy. Thank you-

    Reply

  2. Carol

    Dr. Coe,
    How many days does the 24 hour urine results reflect what you have eaten or drank? Is it that day you are doing it, a day or two before, or longer?

    Reply

    • Fredric L Coe, MD

      Hi Carol, what a great question! For sodium, it is more or less the average of the prior 3 days. For water it is that single collection day. For calcium, it is unknown, and also for oxalate, but probably some kind of several day average. For potassium, phosphate, and magnesium it might well be the day of collection, but I am not sure. See? Lots of research is left to be done. Fred

      Reply

  3. Carol

    Dr Coe, I eat a lot of good carbs and fruits and just wonder if natural sugars increase urine calcium at all or is it just added sugars that do that? Thank you-

    Reply

    • Fredric L Coe, MD

      Hi Carol, fruits are usually fine because quantities of sugar are modest. Fruit juices that extract the sugars are as bad as table sugar. It is this way, how many oranges can you eat at a time? One, perhaps. SO the amount of sugar is too low to matter. Fred

      Reply

  4. TB

    Hello Dr Coe.. I am a calcium phosphate former. 24 HR collection showed all levels good except ..low water intake, low citrate 135, high PH 7.634. Low magnesium 21 and 41, High SS CaP 1.7 and 2.95.. Nephrologist says take pottasium citrate.. Urologist says take magnesium citrate. Other outside consultant is concerned that either one of these could raise my already high ph. Why is my citrate so low and ph so high? My health is excellent except for stone forming and I have none of the known risk factors. What to do???

    Reply

  5. Diane

    Dr Coe,
    In this article it states if Citrate is below 400 to use beverages that provide supplemental Alkali to raise Citrate but would that be accurate also for Calcium Phosphate stone formers since that would raise urine PH even more in already high PH urine? Is it safe to eat a fair amount of fruits and vegs (7-8) a day having a high PH? I see in other articles about using Crystal Light Lemonade for this but doesn’t mention caution with Ca Phosphate stone formers. Do Ca Phosphate stone formers need to worry about increasing their Citrate or best to be mainly concerned with increasing urine volume, lowering urine Calcium by cutting sodium and sugar along with excess protein?
    Thank you!

    Reply

    • Fredric L Coe, MD

      Hi Diane, Whether alkali is good or bad for calcium phosphate stone formers – unanswered because no proper trial. At the moment I try to avoid alkali and work around what is in the urine chemistries as a cause – usually high urine calcium and pH and maybe low citrate. So, reduced diet sodium and sugar, increased volume, and maybe a thiazide – as in the linked article. Regards, Fred Coe

      Reply

      • Diane

        Dr Coe, thank you for answering my previous email and giving me a link to another article. If we are to watch animal protein I find it hard because dairy comes from animal and we need it for the calcium if it’s best not to use supplements. Does the dairy significantly raise an already high urine PH, should a Ca Phosphate former use some supplements rather than all dairy to get the needed calcium so the PH doesn’t rise? Also I have high urine phosphorus of 900 which I’m sure is from dairy, wheat, and bran in the diet, is this a concern for Ca Phosphate formers? I don’t see too much mentioned about urine phosphorus importance in preventing these kind of stones. Thank you!

        Reply

        • Fredric L Coe, MD

          Hi Diane, Milk comes from animals but has a different protein composition than the animals’ bodies, thus have not even the modest stone risk increase of meat. Milk does not raise urine pH, but may slightly lower it. Phosphate matters but not in the range you note. It is the fraction of the phosphate that has two charged sites where protons were – the acid radical – and that is so controlled by pH the amount of phosphate pales by comparison. So, milk is not a risky way to get calcium. Regards, Fred Coe

          Reply

        • Fredric L Coe, MD

          Hi Diane, I think I answered this question from another page, but here again just in case. Milk from an animal does not raise stone risk at all, meat from that animal might at high intakes. Urine phosphate reflects intake and has little effect on calcium phosphate stone formation because what matters most is the fraction of the phosphate with 2 negative charges – this is determined by pH. Regards, Fred Coe

          Reply

  6. Jill

    Hi Dr Coe,
    Thank you so much for all this wonderful information. I am trying to decide if I should repeat my 24 hr urine or not. I ate normally the day I collected it. It was a hot day and I exercised a lot, and therefore drank a lot–more than usual (which I now know is problematic for accurate results!). My stones are calcium oxalate. My 24 hr Ca was 129, Ox 24, Cit 718 and pH 6.077, Na 87. The SSCaOx was 1.63, presumably low bc I drank a lot. Even if I drank a lot, the 24hr Ca, Ox, Cit and pH are absolute values and should be the same regardless, is this correct? If so, there is nothing to change in my current diet and I should be safe if I continue to drink 3L a day. Should I do another urine and eat pizza and spinach salad to see what happens? Should I do another one and just drink 2L (which would be soooo much easier to live with) and see what happens? Thank you so very much for all you do for the kidney stone community:-)

    Jill

    Reply

    • Fredric L Coe

      Hi Jill, Very sharp reasoning. But on hot days we become salt depleted and that can lower urine calcium. Just as a precaution measure again in more temperate weather. As for a lower volume, of course try it. If SS values stay reasonable, perhaps you are done. But why did you form stones in the first place? Were you once unenthusiastic about fluids? Where there other changes. Something caused stones, and now we have all innocence, all normal values. Regards, Fred Coe

      Reply

      • Jill

        Hello again–thanks so much for the reply! I believe you are a treasure of clinical medicine and have likely educated generations of physicians. Thank you!!

        I have passed 4 stones from the left in the past year, all with only mild to moderate difficulty. The left is now clear, per the scope I had last month, the only residual is 2 RANDALL’S PLAQUES in the L upper pole (perhaps this is the risk factor for me, even though my 24hr urine is nl).

        I agree, the “why did the stones form” question is bothering me as well!!! I have a few theories. In my younger days (I am now in my 50’s, fit and healthy) I did not drink very well at all… I did flirt with the South Beach Diet (low carb high protein) for a while….now I eat 2-3 well rounded meals a day and exercise pretty vigorously 3-4 days a week. I also climbed a big mountain this past summer which required being roped into a team while we traversed multiple glaciers– I seriously dehydrated myself for several days in efforts to not have to pee in the middle of the glacier with all my rope team-mates looking on! I ate a LOT of cashews and almonds on that trip as well….(but the stones on the left were all formed prior to this adventure).

        On my right, I have been completely asymptomatic, but when investigating the symptoms of the left it was discovered I had a 2cm mass of many small stones clustered in the R upper pole. My Dr thought maybe caliceal diverticulum, but on fluorscopic dye study the anatomy was normal. So, I have had ESWL x 1, and will have another very soon–hopefully that will be all I need!!! There may be Randall’s Plaques there too, but we don’t know and no scope is currently planned.

        My questions are:
        Do the Randall’s Plaques mean I have definitely had hypercalciuria at some point?
        How long do these stone take to form–have I been working on them for many years?
        Maybe I’ll never have another one now that my 24hr urine is normal?
        I also wonder (because I love spinach…) do non-stone formers excrete a lot of oxalate after eating spinach? Why do they not form stones? Is there a chance I can still eat spinach, even though my stones were CaOx??

        I will take your advice and repeat the24 hr urine study–I’ll probably wait a few months til I’m recovered from the ESWL scheduled for next week. I will drink 2L, not exercise, and eat a normal diet on a temperate day.

        Your contributions to this site and to the scientific literature make a difference in many lives. Thanks again for everything!

        Jill

        Reply

  7. Robert

    Hello Dr. Coe. My 24-Hour results had only 2 high risk areas: Urine Citrate (335 mg/d) and Urine Phosphorus (0.48 g/d). All the other parameters–including Urine Oxalate (25 mg/d)–were normal or low risk. I’m now increasing my water and potassium citrate intakes. For additional help, should I tend toward eating high- or low-oxalate food groups? Many thanks for your fine web contributions for us stone growers!

    Reply

    • Fredric L Coe

      Hi Robert, If your urine oxalate is 25 mg/d there is no reason to bother with diet oxalate. The low citrate is marginal making me wonder why you made stones. I wonder if you might have made them at another time in your life when things might have looked a lot different. Drink lots of water and think about the past. Maybe you might get some more clues. I take it your supersaturations, urine calcium etc all are unremarkable. Regards, Fred Coe

      Reply

  8. kevin

    Hi Dr. Coe, my nephrologist suggested I visit your website and try reaching out to you as new onset to stones 2 years ago now, 1 year on meds and diet adjust and 24 hr urines still way off normal. diet mostly plant based protein, and un processed foods for last 4 years. fluid intake average 1 gallon a day 90% of which is plain water.

    here is last results :
    24 HOUR VOLUME 2.42 L/day
    PH 6.9
    CALCIUM 24 HOUR URINE 577 mg/day
    OXALIC ACID 24 HOUR URINE 40 mg/day
    URIC ACID 24 HOUR URINE 1,193 mg/day
    CITRIC ACID,24 HOUR URINE 2,141 mg/day
    SODIUM 24 HOUR URINE 387 mEq/day
    SULFATE 39 mmol/day
    PHOSPHORUS 24 HOUR 2,047 mg/day
    MAGNESIUM 24 HOUR URINE 232 mg/day
    AMMONIA 24HOUR URINE 44 mEq/day
    POTASSIUM 24 HOUR URINE 117 mEq/day
    CREATININE URINE 2,331 mg/day
    CALCIUM OXALATE 1.56
    BRUSHITE 7.20
    SODIUM URATE 6.14
    STRUVITE 14.17
    URIC ACID 0.30

    Reply

    • Fredric L Coe

      Hi Kevin, From the numbers, your urine calcium and oxalate are very high, citrate is very high, pH is high, and SS for calcium phosphate remarkable. I presume the urine is not over-collected and that the very high creatinine just reflects high muscle mass. Such massive sodium loading is surely raising your urine calcium, and I would start there – you are over 3 times above the US tolerable upper limit for diet sodium. The plant based diet is giving you lots of potassium and alkali so your urine pH is high which predisposes to calcium phosphate stones. My initial concern would be to get the diet sodium down drastically. It is so high that nothing can be done. If your nephrologist wants more detailed help for you from me, please let me know as that would amount to medical consultation. Regards, Fred Coe

      Reply

  9. Lorna

    As a newbie stone former at nearly 60 and a physician myself I have found your information amazingly helpful. Thankyou.

    Reply

  10. Alice

    Hi Dr. Coe, I have managed to lower my SS CaOx from 17.51 to 5.00, lower my SS UA from 0.49 to 0.02, my Ox 24 from 101 to 29. Calcium and citrate are normal. But my SS CaP rose from 1.61 to 2.47. Also my pH rose from 6.290 to 7.447. I was taking calcium with meals and magnesium citrate. Thank you. Ca 24 is 141 and Mg 24 is 299.

    Reply

    • Fredric Coe, MD

      Hi Alice, Perhaps the magnesium citrate is too much of a good thing – or perhaps the calcium is calcium citrate or calcium carbonate. Those will raise urine pH. Can you not use calcium foods at least in part? Otherwise you seem pretty good at changing things. Regards, Fred Coe

      Reply

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