24 hour Urine Calcium - Bad-Good-Confusing!

Lela52
  • By Lela52 · August 23, 2012 at 6:03 pm · 26 replies
  • In Diseases, conditions and other causes of bone loss
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I've done two 24 hour urine Calcium tests.
23rd of July 2012 Calcium 533 mg/24h (My Lab's ref value 100-350)
16th of Aug 2012 Calcium 225 mg/24h (My Lab's ref value 100-350) & Phosphat 619 mg/24h (My Lab's ref value 500-1300)
With the result of my 1st test my family doctor "reached for the prescription pad", he said it can be lowered with diuretic. He agreed to check it again first and added Phosphat as he said "they are connected".

After my 1st test I talked to my "Osteo coach" Dr Keith McCormick, he said:
"Check it again and this time really make sure you DO NOT take your calcium supplements the 24 hours before the start of the test or during the 24 hours of the test. So many times I see people high in this test simply because they took their calcium supplements the day before the test. Eat your regular diet including any dairy you normally eat though."

So by doing the test exactly like he said my 2nd turned out normal. And it isn't a borderline normal it is well within my Lab's ref value !
Not my family doctor nor my lab gave me any instructions before the test, only how to collect so I got 24 hours. So I knew nothing about restricting calcium supplements 24h before and during the test. I took my supplements (around 900mg Calcium) and ate my normal diet.
I wonder how many people get unnecessary diuretic prescriptions due to doing the test like I did the first time?

I have researched a little(!) what instructions are "out there".
But I have found many different instructions... !
1. "Drink the usual amount of liquids, eat your normal diet, and take the usual vitamins, calcium, and medications during the collection period."
2. "Do not take Calcium or Vitamin D supplements on the day of your collection and do not consume more than 400mg of dietary calcium on the day of collection"
3. "Ref value Adults: <300 mg/24 hours with low dietary calcium intake of 200 mg/24 hours" (I found that same instruction at the Medical University of South Carolina)
4. "Ref value Males: 25-300 mg/specimen* Females: 20-275 mg/specimen* Hypercalciuria: >350 mg/specimen *Values are for persons with average calcium intake (ie, 600-800 mg/day). Increased urinary excretion of calcium accompanies hyperparathyroidism, vitamin D intoxication, diseases that destroy bone (such as multiple myeloma), metastasis from prostatic cancer, and following calcium supplementation. Patients with absorptive hypercalciuria (increased gut absorption) will have lowered urine calcium with dietary restriction and, therefore, can be differentiated from patients with hypercalciuria caused by hyperparathyroidism, hyperthyroidism, Paget's disease, or "renal leak" type of calciuria as seen in renal tubular acidosis."
5. "a 24-hour urine specimen at least 2 weeks after stopping calcium supplements while continuing the usual dietary calcium intake" (page 25 of www.endojournals.org/site/translational/osteoporosis.pdf).

I will look for more instructions and interpretations of the 24 hour urine Calcium test but I wanted to post what I've found so far. Isn't this confusing?
Wouldn't it be nice if there where some sort of consensus?? What do you all think? Maybe this has been discussed before? /Lela

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26 replies   

arrowsp

I guess my question would be, why are you doing this test? Have you already tested Ionized serum calcium and PTH? If so, from those figures you will know whether your high blood calcium (if that's what shows up) is due to overactive parathyroid. And the high urine calcium just confirms that your body is try to get rid of all this calcium that your parathyroids are pulling out of your bones.
Or are you having the test done for a different reason?

Lela52

arrowsp, Thank you for answering.
I have never done this test and it is to my knowledge on the list of tests to do when looking for second causes to osteoporosis.
High levels are seen in for example idiopathic hypercalciuria, and low levels can suggest malabsorption is what I have read. I did the blood tests Calcium total, Calcium Ionized & PTH at the same time as my 1st 24 h Urine Calcium and the blood tests where normal.

mammaof4boyz

I am so glad to read your post I am doing the same test and like you was not given any instructions excpet how to collect the urine.

Lela52
  • By Lela52
  • Reply 3316604 · In reply to 3316469 by mammaof4boyz
  • August 23, 2012 at 11:33 pm
  • Report post

mammaof4boyz,
You see ... this is a good place. I'm still looking around for more info and I've read a few earlier discussions about this now and it looks like more people have experienced the same thing. I also found this article that I marked as;
This looked like very good info about Urine Calcium ! http://www.cigna.com/individualandfamilies/health-and-well-being/hw/medical -tests/calcium-in-urine-hw27965.html More reading tomorrow..

dxaguru

Thank you for doing some valuable research into the proper method for performing a 24hr urinary calcium level. Our lab places instructions on refraining from taking calcium supplements for 3-7 days and during the day of the collection right on the jug.

And yes, the fact that you are excreting excess calcium above what your body acutally needs was demonstrated by the normalization after stopping. What is tells you is that you are probably flushing a lot of money down the toilet taking more calcium supplelent than you need to. Recent data suggests that excess calcium may be bad for the heart (and that calcium can also lead to the development of kidney stones. It is the perfect example of more is not better, and good evidence that your intestines can absorb calcium properly.

A low urinary calcium output, even in someone who is taking large amounts of supplements is a much more worrysome result and usually is associated with elevated PTH levels as the parathyroid glands compensate for low intake and stimulate bone resporption to keep the serum calcium level normal.

Daisy2002

I just had that test done (no results as of today). Like you, I was not told anything except keep urine bottle refrigerated. What is wrong with these people. They need a sheet of info to pass out to us. Thanks for sharing. Wish I had read it sooner.

Lela52
  • By Lela52
  • Reply 3317895 · In reply to 3316971 by dxaguru
  • August 24, 2012 at 12:58 pm
  • Report post

dxaguru, Thank you for your reply. I've added your Lab's instruction to my "collection".
I hope I can trust your reassuring words that my tests gives "good evidence that my intestines can absorb calcium properly."
Your comment regarding Low 24 hour Urine Calcium being "associated with elevated PTH levels" made me have to think a bit.
I interpret that as you are not talking about Hyperparathyroidism - you are talking about (a probable) malnutrition causing too little calcium to be absorbed which causes low blood calcium which causes PTH levels to rise which mobilizes calcium from bones and stimulates the kidneys to reabsorb calcium. Did I get that right? Is that what you mean?

Lela52
  • By Lela52
  • Reply 3317914 · In reply to 3316980 by Daisy2002
  • August 24, 2012 at 1:04 pm
  • Report post

Hi Daisy2002, Yes I totally agree - this is very confusing and even though it doesn't "hurt" to do a retest (when hopefully you have gotten the "right" instructions) it can cause a lot of unnecessary anxiety for us - and we don't need that !!

Lela52

Hi all,
15 instructions is what I have found so far and I think I will stop looking now. You can see them in the chart below.
I hope the text is visible, it is for me if I zoom in on my computer.

If someone is interested in reading more about this subject – here are some links I found while searching for instructions.
I can highly recommend the first link "Bone disease in primary hypercalciuria" - I found it very interesting and plan to read it again (overload of info caused brain cell fatigue the first time ☺)

Bone disease in primary hypercalciuria http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781204/

New Insights into the Pathogenesis of Idiopathic Hypercalciuria http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2362396/?tool=pubmed

Urine Calcium: Laboratory Measurement and Clinical Utility http://labmed.ascpjournals.org/content/41/11/683.full

Variations between two 24-hour urine collections http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289692/?tool=pubmed

Intestinal hyperabsorption of calcium and low bone turnover in hypercalciuric postmenopausal osteoporosis http://www.springerlink.com/content/h221473807877v65/

Hypercalciuria is a common and important finding in postmenopausal women with osteoporosis http://www.eje-online.org/content/149/3/209.abstract?ijkey=c7daf54136d6bfd6 244cfef5326a79f969e39123&keytype2=tf_ipsecsha

When I read through older Inspire discussion on this subject I found 3 members that had the same experience as me, first test high and then with no Calcium supplements a normal value so they didn't need a drug. No one had as high first test as me though.

Now after putting this together I will try to make sense of it too... and according to the review "Bone disease in primary hypercalciuria" it IS complicated so I guess that will take a long time...
In that review they say: "according to the more recent view that dietetic factors can widely influence urine calcium excretion, “true” primary hypercalciuria is considered the form of urinary calcium excess that does not depend on known conditions and in which possible dietetic disturbances have been eliminated by keeping patients on a daily diet with 1000-1200 mg of calcium and no more than 1-1.5 g/kg body weight (BW) of proteins. ... According to the new definition, some patients are no longer classified as hypercalciuric as before. However, it is well-known that a diet exceeding the above-mentioned range for daily calcium and protein intake affects calcium excretion even in patients with no evidence of intrinsic alterations of calcium metabolism, who would be misclassified as hypercalciuric."
Non of the 24 h test instructions I found mentioned Protein though and if they had restrictions of dietary Calcium it was not the figure, 1000-1200mg.

Here are links to the older Inspire discussions:

http://www.inspire.com/groups/national-osteoporosis-foundation/discussion/l ow-urine-output-high-calcium-in-24-hr-test/
www.inspire.com/groups/national-osteoporosis-foundation/discussion/hctz-to- take-or-not/
http://www.inspire.com/groups/national-osteoporosis-foundation/discussion/i diopathic-hypercalciuria/?reply_sort=asc&page=2#replies
https://www.inspire.com/groups/national-osteoporosis-foundation/discussion/ calcium-renal-leak-diagnosis-24-hr-urine-test/?reply_sort=asc#replies


Bild 12
Bild 11
Links to Sources:
1. www.endojournals.org/site/translational/osteoporosis.pdf
2. Aug 24th 2012 in this discussion http://www.inspire.com/groups/national-osteoporosis-foundation/discussion/2 4-hour-urine-calcium-bad-good-confusing/?reply_sort=desc#replies
3. http://www.betterbones.com/bonehealth/medicaltestingforosteoporosis.aspx and http://www.betterbones.com/bonehealth/understandingosteoporosistestresults. aspx
4. Personal advice. (I can't find instructions in his book) http://www.inspire.com/DrRKeith/ http://shop.osteonaturals.com/product/the-whole-body-approach-to-osteoporos is
5. http://www.vanderbilthealth.com/endocrinology/30817
6. Personal advice.( I can't find instructions in her book) http://www.inspire.com/LaraPizzorno/ http://www.amazon.com/Your-Bones-Prevent-Osteoporosis-Naturally/dp/16076600 75
7. www.muschealth.com/lab/labtest.aspx?id=150182
8. http://www.allinahealth.org/ccs/doc/Consumer_Lab/49/150182.htm
9. http://www.mayomedicallaboratories.com/test-catalog/print/8594
10. http://www.nlm.nih.gov/medlineplus/ency/article/003603.htm
11.http://www.cigna.com/individualandfamilies/health-and-well-being/hw/medical -tests/calcium-in-urine-hw27965.html
12. http://www.nmbonecare.com/PI%20Osteoporosis%20Evaluation.html
13. http://courses.washington.edu/bonephys/opdiagnosis.html
14. http://www.walkinlab.com/calcium_urine_test.html
15. https://healthonline.washington.edu/ (search: calcium)

Syr1

Yeah, the matter is quite confusing.
I didnt stop any supplement nor change diet when I did 24h calcium test and it was borderline high (around 370 with 100-400 normal range for my lab).
I do not plan to repeat the test, there are more useful tests that can be run (such as PTH, FSH, ionized calcium), but I can say that it excluded calcium malabsorbtion.

Sandi-sdivas

Lena52
You've put a good deal of time and effort in finding all of this information and posting the links for the community. Thank you very much. Your information will be helpful for many community members.
Sandi

Lela52

Syr1, thank you for replying.
Yes I see that your test result turned out normal so I can understand why you have no plans to repeat the test.
But as I understand it this 24 hour urine Calcium test is a valuable tool for detecting for example idiopathic hypercalcuria.
I didn't receive any instructions at all so like you I didn't stop any supplement nor change diet and in my case it turned out high.
Same thing, no instructions before my retest, so if I hadn't asked for advice elsewhere and been informed how to prepare for the retest then I guess it would have been high once again and I'd been given a drug? I wonder if this is happening to others too?
I thought my family Doctor & the Lab just had missed to give me the information but when I started to look for instructions "out there" that's when I got really confused...

sdivas, Thank you so much for your kind words !

darlingorla

Very useful post. I didn't know about stopping calcium supplements etc. prior to testing. Nobody bothered to tell me - their only concern being that the huge pee bottle had to be refrigerated between use ... I ended up on a diuretic for 16 years by one endo and then another took me off the drug (Thiazide) exclaiming that I didn't need to be on it - needless to say I am more than skeptical now about doctors having also been put on HRT for 7 years against my better judgement - and then being taken off it when the 'Report' came out in 2002 and I was quickly taken off the drug like many other women. um ...

Lela52
  • By Lela52
  • Reply 3325186 · In reply to 3324714 by darlingorla
  • August 27, 2012 at 12:20 pm
  • Report post

Hi darlingorla,

Thank you very much for sharing your experience with us ! Can I ask;
Did you get a diagnose? and how did they monitor that the diuretic worked for you? Where you retested now and then with this test during the 16 years you where on the diuretic? And if you did retest did you get instructions before these retests? What made your second endo decide you didn't need it - do you know? It is so bad if it turned out you took medication unnecessarily for 16 years!

Sorry, a lot of questions...the thing is that I am a "need to understand" person and having an education in clinical chemistry (worked as a Biomedical analysts at a hospital, responsible for the test quality at smaller Labs) does add to my confusion.
I can not understand why there isn't a consensus about how to prepare for this test !
The reference values must have been developed in a certain way? How where these people preparing for the test?

Yes a few of the sources in my chart have given different ref values depending on calcium intake but does that apply for just the day of the collection? or what? One source says: "You may be asked to follow a special diet that is either high or low in calcium for several days before the test." And if alcohol and protein and vitamin D and ... and... is also of concern, as stated by some sources, can that really apply to only some Lab's? Most likely that is an information that should also be given to us. Nor is it easy for people to calculate their dietary calcium intake either, so that adds to the problem.

I did my 1st collection on a Sunday, on Saturday & Sunday I had yogurt for lunch and meat (protein) for dinner, it was nice weather so we used the grill outside if I remember correctly - I also had wine to these dinners - and I took my vitamin D & calcium supplements.
Should/Can I "forget" my first test result? Or does it actually mean something that it was really high ?
If some people who "live as usual" before & during the collection get normal results no matter what - are they "more normal"?
Still confused ...

I did read a long interesting article yesterday that although it seams to be aimed for hypercalciuria in regards to potential kidney stones, it also mentions Osteoporosis; http://emedicine.medscape.com/article/436343-overview#aw2aab6b2
This article also talks about the different kinds of hypercalciuria and how to diagnose them. I don't know how often this is done though or if it matters regarding how it is treated.

darlingorla, thank you again for replying, hope to hear from you again. Your story is important ! Kind regards /Lela

darlingorla

I did get retested at least 3 times over the 16 year period I took Thiazide - however, I didn't know about the dietary restrictions for the test - just to make sure I refrigerated the jug! I have been reading a lot recently, the 3 books recommended by various participants here on the forum - and what an eye opener that has been - that it is possible, by eating a more alkaline diet, to reduce calcium excretion thru the kidneys without taking a diuretic ... I have now made a conscious decision to exclude red meat entirely from my diet as I really believe that eating it is detrimental to my bones, and to also eat more vegetables (I love fruit) and eat less dairy despite what these doctors are telling me. I think what stands out in my mind is - why do people in countries with the highest consumption of dairy products also have the highest incidence of Osteoporosis? I really feel that half the time these doctors don't really know what they are talking about ...

The last endo/gerantologist specialist took me off Thiazide but didn't really explain why - I have not been back to her again as she scared the pants off me by sending me for x-rays, bone scans because my blood calcium level was slightly higher than normal - all tests came back normal - she was apparently checking for multiple myeloma which I do not have - this was 5 years ago... I go to a naturopathic doctor now and also go for an annual physical with my GP etc.

The reason why I have joined this forum is because I got called into my GPs office 2 months ago regarding my recent BMD scan which showed my results had changed. A year ago my spine was at T score 1.6 (a 10% improvement over previous year) and now is showing T score 2.5 ( a decrease of 10%) My hip value T score of 1.2 is unchanged. She immediately wanted to put me on a bisphonate drug - however, I suggested that there appeared to be a mistake in the testing and she agreed - that it seemed ridiculous to gain 10% one year and then lose 10% the following year. I have left it with her to see whether retesting is appropriate and am still waiting to hear back from her.

I took this as a sign that I really needed to research Osteoporosis more fully. I have been taking Strontium 680 mg for nearly a year now and so was hoping for a better BMD result. I also have osteoarthritis of the spine and I know that it can affect the test and that it would be somewhat prudent to measure my forearm (where there is no arthritis) to give a better picture of my bones, particularly as osteoporisis is systemic disease. However, because I do not go to the gerantologist anymore, the technician will no longer scan my forearm - its all down to dollars and cents ...

alwaysace

I am so glad to read this (wish I would have logged on last week to read it). Just did the 24 hour test yesterday and turned it in this am. Neither my doc nor the lab instructed me to skip calcium supplements in advance. Glad to know this now so if tests come back out of whack I can ask to re-do without calcium before hand! Thank you!

Lela52
  • By Lela52
  • Reply 3329229 · In reply to 3325592 by darlingorla
  • August 28, 2012 at 8:34 pm
  • Report post

Hi darlingorla, thank you for more info !

So 3 retests of 24 hour urine calcium over the 16 year period and no instructions how to prepare before & during the retests either.
That is important information regarding how this treatment is monitored ! Did your results come up high all three times? It is odd that the new endo that took you off Thiazide didn't explain why - I guess you can't get that information now since you "fired her. To me it sounded as she at least was trying to investigate second causes. Did she also check you for hyperparathyroidism ? since your blood calcium level was a bit high ? You said all test came back normal so that sounds good.

Yes I have also read that it is important to help, for instants your kidneys by not giving them too much acids to deal with, by eating more alkaline food. It seems like I need to adjust my diet because my morning urine pH is too low and I've just bought the book "The Acid Alkaline Food Guide" by Dr Susan E. Brown & Larry Trivieri, Jr. It has been recommended on this forum. Just started reading it but it looks like there is a lot of information in it and I hope it will help me.

Regarding your Dexa scan and that you said that you also have osteoarthritis of the spine - please read my discussion:
DEXA can't measure Osteoporosis in MY spine - so what can?
I don't want to be negative but could it be that your 10% improvement the previous year was wrong? If you read the discussion I mentioned you will see that I (obviously) also has arthritis in my spine and I was told that if the technician doesn't disregard the BMD numbers of the arthritic vertebraes then the Dexa result looks like a (false !) great improvement. Did you have the same technician doing the DEXAs both times? I was suggested to trust Dexa readings of my hip, obviously hips aren't effected of arthritis as much as the spine and also to talk to the technician to be sure they didn't include arthritic vertebraes in their calculation. The last bit is my own interpretation of this. Actually I think it is their job to know how to do this but obviously a lot of technicians and Doctors who signs these results don't care enough to react when BMD numbers look suspicious - mine didn't react anyhow. Your Dexa result of the hip looks very good to me and they hadn't changed, that also sounds good doesn't it? You could ask member dxaguru about your Dexa tests, he knows a lot about these things.

Best of luck to you ! and if you do a retest of the Dexa (and 24 h urine calcium?), I hope the results will be good. /Lena

Lela52
  • By Lela52
  • Reply 3329302 · In reply to 3325882 by alwaysace
  • August 28, 2012 at 9:04 pm
  • Report post

Hi alwaysace,

I'm glad you logged in now and replied and I hope your test will turn out normal. If your test will be high maybe your Doctor will tell you to do a retest and give you instructions then ? That seems to be the way Dr. Susan Brown (The Center for Better Bones) use this test - see source NR 3 in the chart I posted. Please let us know how this works out for you and what your doctor says. Good luck /Lela

Sandi-sdivas

This weekend, I will be doing a retest 24 hr urine test. The container I was given does not have any directions about supplements or calcium. I asked if there was anything specific I needed to know for the test. I was told not to use the first void. I asked about vitamins, minerals, calcium. I was told I didn't have to stop taking any of my minerals, vitamins, or calcium unless told by my doctor. My doctor has not given me any specifics for the test. My information for the plan I have taken in preparation for the retest has come from community members that have gone through the same experience. It may be that if I didn't have any calcium lost through urine, it wouldn't make any difference whether I took calcium prior to the test or not .... but I'm going to lean on the side of the suggestions NOT to take calcium. In fact, since I'm taking the retest this weekend, I discontinued all minerals, vitamins and calcium yesterday. I'm giving myself a full week. Maybe what I'm doing will not make a difference. I'm only slightly above what the lab in my area considers the norm, but at least I'm going into the retest doing what might make a difference. I'll let you know when I receive the results. I continually learn that the experiences of community can be valuable information and often can make a difference.
Thanks.
Sandi

Daisy2002

Lela52

A couple of weeks back you asked me a question regarding my 24 hour calcium test. I can no longer find that post, however, the answer to your question follows:

I did not talk to my doctor but talked to one of her assistants. I told her that no one told me not to take supplements so I had taken them before the 24 hour test. She said " whether you take calcium supplements before the test does not make a bit of difference".
I let it go with that. I had called them to check on my results when I informed her I took supplements. Since my test was normal I will not be talking with my doctor for another year.

Thanks so much for all of your research on this subject.

Regards,

Nancy

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