What are your management strategies for patients with recurrent uric acid nephrolithiasis and chronic kidney disease who have persistent hypocitraturia and acidic urine pH?

This is a good question. The primary goal is to correct the urine pH to at least 6 and preferably 6.5, regardless of renal function. Hypocitraturia is not a critical issue in uric acid stones disease, though it will likely respond to therapies listed below. Concurrent chronic kidney disease does not alter the pH goal, but CKD may limit appropriate options, as do other comorbid illnesses. Since protein catabolism generally is the source of acid generation in the body, I screen for protein glutton...

I agree completely with Dr. @Dr. First Last's scholarly answer. One additional thought: The underlying pathophysiology is likely the loss of ability to convert glutamine to glutamate in the renal proximal tubule. This is commonly seen in type 2 diabetics with advanced chronic kidney disease but can be seen in any advanced CKD. The loss of urinary ammonium results in hyperaciduria and often uric acid stones.

Stephen B. Erickson, MD