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If you have ever had a kidney stone or worry you might form one, calcium oxalate supersaturation (CaOx SS) is the single most informative number on a 24-hour urine panel. It tells you whether the chemical conditions inside your urine right now favor crystal formation. A value above 1.0 means your urine is oversaturated: crystals can begin to form and grow. A value below 1.0 means crystals would dissolve. Think of it like a tipping point. The higher your number climbs past that threshold, the greater the push toward stone formation.
What makes this number so useful is that it does the math for you. Rather than trying to interpret your calcium, oxalate, citrate, magnesium, pH, and urine volume separately, supersaturation folds them all into a single index. People with a relative supersaturation above 1.0 have roughly six to seven times the odds of having formed a symptomatic kidney stone compared to those below that line. That integrated view is why many kidney stone specialists consider it superior to any individual urinary measurement.
Supersaturation is not something your kidneys produce. It is a calculated ratio: the concentration of calcium oxalate in your urine divided by the maximum amount that can stay dissolved. Specialized software (such as a program called EQUIL 2) uses your 24-hour urine results to compute it. The output captures the net effect of everything pushing your urine toward crystal formation and everything holding crystals at bay.
Two factors exert the strongest pull on your number: urinary calcium and urinary oxalate. Both are equally effective at raising supersaturation in standard calculations, though some theoretical models suggest oxalate may be up to 23 times more potent than calcium under certain conditions. On the protective side, citrate and magnesium act as inhibitors, binding calcium or oxalate so they cannot join into crystals. Low citrate or low magnesium weakens that defense.
This is worth knowing because it shapes what you can do about an elevated result. Lowering calcium or oxalate input pulls the number down. Raising citrate or increasing your urine volume also helps, because a more dilute solution is harder to oversaturate.
Supersaturation is not just a laboratory abstraction. It tracks with what is actually happening inside your kidneys. A study using CT imaging to measure stone volume over time found a clear dose-response relationship.
| Who Was Studied | What Was Compared | What They Found |
|---|---|---|
| People who form pure calcium oxalate stones | Annual stone growth in the low-risk supersaturation group (score below 4) | Median stone volume grew 15% per year |
| Same population | Annual stone growth in the moderate-risk group (score 4 to 10) | Median stone volume grew 59% per year |
| Same population | Annual stone growth in the high-risk group (score above 10) | Median stone volume grew 111% per year |
Source: Yuzhakov et al., The Journal of Urology, 2021.
What this means for you: if your supersaturation falls in the high-risk zone, stones in your kidneys are not sitting still. They may be roughly doubling in size each year. That is the difference between a stone that stays small enough to pass on its own and one that eventually requires a procedure.
Your result will vary depending on the laboratory's software and reference method, so always interpret your number within the ranges your specific lab provides. That said, general risk categories have emerged from research.
Among 24-hour urine samples studied, roughly 15% are unsaturated (crystals would dissolve), about 80% fall in a metastable zone (crystals could form but do not always), and around 5% reach critical supersaturation where crystal formation is highly likely. Notably, low citrate and low magnesium are present in 63.8% to 80% of samples at every saturation level. This means even people whose calcium and oxalate look normal may be at risk if their protective inhibitors are low.
A large study of 24-hour urine collections found that people in the highest supersaturation category had approximately six to seven times greater odds of a symptomatic stone compared to those in the lowest category. This gradient held after accounting for other factors, reinforcing that supersaturation is not merely a surrogate for high calcium or high oxalate alone.
Because supersaturation is a composite number, you can shift it through several different levers. The research supports the following approaches.
Fluid intake: Increasing urine volume dilutes all solutes and lowers supersaturation directly. This is the simplest and most universally recommended intervention. The American Urological Association guideline recommends targeting sufficient fluid intake to produce more than 2.5 liters of urine per day.
Dietary oxalate reduction: Since oxalate is one of the two dominant drivers of calcium oxalate supersaturation, reducing high-oxalate foods (such as spinach, nuts, and chocolate) can meaningfully lower your number. This is especially important if you have a bowel condition or have undergone bariatric surgery, because malabsorption increases oxalate absorption in the gut.
Dietary calcium (not restriction): Counterintuitively, adequate dietary calcium helps because calcium binds oxalate in your gut before it reaches the kidneys. Restricting calcium can actually raise oxalate absorption and worsen supersaturation.
Sodium reduction: High sodium intake increases urinary calcium excretion, which pushes supersaturation up. Lowering sodium can reduce urinary calcium and thereby lower your number.
Citrate supplementation: Because citrate inhibits calcium oxalate crystallization, potassium citrate is one of the most commonly prescribed medications for stone prevention. It raises urinary citrate and can lower supersaturation, particularly in people with low baseline citrate (which is present in the majority of stone formers at every saturation level).
Thiazide diuretics: These medications reduce urinary calcium excretion and are used in people with high urinary calcium who continue forming stones despite dietary changes. By lowering the calcium component of supersaturation, they can bring the overall number down. This is a prescription intervention best discussed with a clinician.
The American Urological Association guideline emphasizes that specific nutritional therapy informed by both diet assessment and metabolic testing (including supersaturation) is more effective than general dietary advice alone in preventing recurrent stones.
After starting any intervention, a follow-up 24-hour urine collection within six months is recommended to see whether your supersaturation has actually moved. Annual collections after that help track whether your strategy is holding.