Although inorganic sulfate is an essential and ubiquitous anion in human biology, it is infrequently assayed in clinical chemistry today. Serum sulfate is difficult to measure accurately without resorting to physicochemical methods, such as ion chromatography, although many other techniques have been described. It is strongly influenced by a variety of physiological factors, including age, diet, pregnancy, and drug ingestion. Urinary excretion is the principal mechanism of disposal for the excess sulfate produced by sulfur amino acid oxidation, and the kidney is the primary site of regulation. In renal failure, sulfoesters accumulate and hypersulfatemia contributes directly to the unmeasured anion gap characteristic of the condition. In contrast, sulfate in urine is readily assayed by a number of means, particularly nephelometry after precipitation as a barium salt. Sulfate is most commonly assayed today as part of the clinical workup for nephrolithiasis, because sulfate is a major contributor to the ionic strength of urine and alters the equilibrium constants governing saturation and precipitation of calcium salts. Total sulfate deficiency has hitherto not been described, although genetic defects in sulfate transporters have been associated recently with congenital osteochondrodystrophies that may be lethal. New insights into sulfate transport and its hormonal regulation may lead to new clinical applications of sulfate analysis in the future.