Problems in the Metabolic Evaluation of Renal Stone Disease: Audit of Intra-individual Variation in Urine Metabolites

Preliminary metabolic assessment of patients with renal stones includes measurement of urine metabolites. This paper reports on the degree of intra-individual variation in some key urine metabolites. Over 80 medically untreated patients under initial metabolic investigation were audited from whom 24-h urine results were available as three separate urine pairs collected at intervals not less than 1 month apart. Ranking patients by intra-individual variation, above the 75th centile, the highest calcium was at least 216% of the lowest calcium, the respective figures for phosphate, urate, oxalate, citrate, creatinine and sodium were 207, 190, 271, 412, 175 and 233%. In order to estimate pre-treatment excretion within 30% of a true mean at the 95% confidence limit, for calcium and oxalate, the number of 24-h samples required were 3 and 4 respectively with 6 and 9 required to be within 20%. These observations illustrate significant practical clinical problems in assessing patients with renal stones when assessing these basic parameters. Regimens based on small numbers of urine collections are flawed, hence evidence based protocols should be devised. A minimum of three pairs of 24-h urine samples based upon predicting metabolite output within 20-30% or less of the true mean is recommended.