"Citrate," he says. "Not enough citrate."

Saw my new-ish uro again yesterday.  Well, **** too.

He says I have stones because, like all of his wls patients with stones, I don't have even a tiny bit of citrate in my system.  (Sometimes stones can also be there because of not enough water, but since I almost had to hire a couple of sherpas to help carry my 24-hour urine collection in for testing, that isn't MY problem.)  Last test I had not enough to really count, but for sure it was less than 18% of the LOW end of the reference range.  It could just as easily be 1%, we don't know...not enough to count.

And, I called the manufacturers yesterday and the people on the phone at Bariatric Advantage don't even understand the question, but the nice guy from Solgar who called me back explained that the word "citrate" on the labels of stuff like Calcium Citrate and Magnesium Citrate indicate a "processing method" and the reason that there is no separate listing for citrate on the label is that there is essentially only trace amounts of citrate in the supplements.

That's just to let y'all know that that word citrate on the label doesn't mean you're supplementing citrate.

Back to ME!! 

For the next three more weeks, I'll take a couple of oral citrate supplements.  The pill is a mess because it's a time release thing and the liquid...well they should be SUED for saying that's it's pleasant-tasting because it is pleasant-tasting only if you are a maggot.

After three weeks, I do another 24-hour urine collection.  You all will be prepping for Thanksgiving and I'll be here with NOTHING to do except collect urine for 24-hours.   Expect snark.  At that time, if the citrate gets me anywhere near the bottom end of the reference range, I'll keep taking it and we'll work with it.  But if all it does is move me from <50mg/L to say 100 mg/L then we're not going to bother with it.  (Kind of like jumping off a 10-story building rather than a 50-story building.  Maybe smaller pieces to deal with, but just as dead at the bottom.)

And I'll do another x-ray at that time to see if the stone is getting smaller.  If it's breaking up on its own, we won't do anything, but when has it done what we wanted?

So, we will PROBABLY decide to go in with a scope after that, probably the second week in December, since I've already hit my "Out of Pocket Stop Loss" this year and the lovely folks at Anthem BC will be buying lunch for the good doctors.  (Same reason I'm having two dental crowns redone and I have a pair of glasses to pick up at the optometrist's.)

Here is the progression.  Plan A hasn't worked too well.  December might be Plan B.  I'm hoping to avoid Plan C.

• Extracorporeal Shockwave Lithotripsy (SWL) uses an x-ray machine to locate the stone.  Sound waves break the stone into pieces small enough to pass in the urine.  This works in about 85% of the cases that need treatment.  This treatment works best for small stones in the upper urinary tract.  The sound waves pass through your skin, there is no incision.

 

• Ureterorenoscopy can be used to treat almost any small kidney stone.  A small scope is placed into the urinary tract.  A laser breaks the stone into pieces that can be passed in the urine.  Most patients go home the same day.

 

• Percutaneous Nephrolithotomy (PCNL) treats very large or complex stones.  A small incision is made in the back to reach the kidney.  A thin wire placed into the kidney removes the stone.  This requires a hospital stay.

There is, according to this uro, damned little people with severe citrate malabsorption can do to replace enough citrate.  This does not make me smile.

Dammit, I suddenly have to pee after reading your post! 

Funny you should post this.   I just pulled out my lab results to PM you, and here I find this post.    It kind of sounds like you are a candidate for the PCNL, but damn that sounds icky.
That's kind of bad news on the citrate front.  I've been trying like hell to find everything with citrate, and my understanding then is that I'm wasting my time?

So here are some of my out of range results for my 24-hour urine work-up

Cystine                                  Non detectable                      (range 10-100)
Calcium (urine)                   42                                             (range 100-300)
Citrate                                   12                                             (range 280-1240)
Oxalate                                  135                                          (range less than 42)
NTX (BCE)/Creat Urine      84                                             (range 5-65)

Crap, you're a mess, too, aren't you?

So yes, we may be wating our time looking for stuff with citrate in it.  I put my pharmacist on the job and she came up with the ones my uro wrote the scripts for.

I know nothing of the science except that we try and then test.  So don't asume you can't absorb the citrate without giving it a try.  Right now I've ben prescribed UroCit-K 15 mEqs to be taken twice a day  AND Cytra-K Oral Solution--the nasty stuff--which they would like me to ingest at the rate of 3-6 teaspoons after each meal and at bedtime...because apparently they think I'm a glutton for punishment.  And then another 24-hour test.



So, yeah, you're a mess, too.

Cystine                             Non detectable         (range 10-100)
Calcium (urine)                  42                            (range 100-300)
Citrate                                12                            (range 280-1240)
Oxalate                             135                            (range less than 42)
NTX (BCE)/Creat Urine      84                            (range 5-65)


We have different ranges, but mine--for some of those tests--were:

Cystine                             Negative
Calcium (urine)               171.5                           (range 8.5 - 277)
Citrate                             <50mg/L                      (range 287-708)
Oxalate                           187.9                           (range 5.4 - 37)


I'm now taking my calcium when I eat oxalate stuff...and I'm trying those citrate things.  We'll see if it improves.


The hard part for me right now is that "nothing's wrong."  I'm not in any pain.  NOthing is cancerous.  It's just that I've got a big old honkin' kidney stone and we KNOW that the minute I leave the county its going to try to get out.  My LAT ambulance ride out of Yellowstone was five hours and $3000.  And no fun.  In kidney stone pain, it would be awful.  So I feel like that cartoon dude from the olden times who, no matter where he went, there was a dark cloud over his head.

I am going to display my ignorance here: To develop kidney stones, a person must be absorbing  calcium into the bloodstream----right? Out of curiosity, have your serum calcium, dexascans I.calcium's been within normal limits?
I'm also hoping that a chemist out there will chime in. Since the mag citrates, cal citrates, etc. that we consume in abundance are bound, then unbind to become bio-available in our bodies, what happens to the citrate portion of the molecule? Does it bind with something else in the gut and get excreted in stool? What form of primary citrate is easily bio-available?

Thanks, in advance

My serum calcium is right in the middle of normal.  I'm 63 and my dexascan says...well..that I'm not 26 anymore.  But I don't have osteoporosis, either.

A book I read on the topic says that the calcium-stone relationship goes like this:

~plants need oxalates and we don't.
~generally, the oxalates in foods combine with the calcium in the gut and the oxalates leave via the stool.
~but we don't absorb the calcium, so it's not there to pair up with the oxalates.
~so we absorb the oxalates,
~and they find their way to the kidney where they meet up with some calcium, and make stones.

My uro didn't jump on this explanation, he's focused on the lack of citrate being the culprit.

The only flaw in your discussion is this:

~generally, the oxalates in foods combine with the calcium in the gut and the oxalates leave via the stool.
~but we don't absorb the calcium, so it's not there to pair up with the oxalates.
~so we absorb the oxalates,

The calcium and oxalates need to combine in the gut to leave via stool -- so our absorption (or lack thereof) of calcium has nothing to do with it -- the calcium you take is in your gut where it needs to be to combine with the oxalates.  Why that isn't happening, and that you are absorbing the oxalates anyway, is a puzzlement.

I'm not sure how that information helps, other than to recommend that you take your calcium WITH your oxalate-containing meals.

I do...except for yam medallions.  I skip it when I eat yam medallions.

Okay, YOU paraphrase it...since you actually passed a science class or two.

On pages 62 and 63 in here:
books.google.com/books

My interpretation of that document is that the calcium in our intestines is bound to fat (I didn't think this was a major problem), and therefore is unavailable to bind with the oxalates.

The summary given is, "Therefore, any bowel disease [or intended surgical modification] that causes fat malabsoprtion causes more oxalate to be absorbed in the large intestine."

In more detail: typically calcium and oxalates bind in the small intestine. You have a lot of extra fat in your small intestine since most of it is not absorbed, and none at all is absorbed until your common channel. Oxalates are well-absorbed by the large intestine, and in a normal anatomy, they don't typically make it that far because they have bound with calcium by that point.

So, one thing you could try is isolating oxlates to meals that are not high in fat. Or you could try adding calcium with high-oxalate foods. Or both. Or just cut down on oxalates. Or all three.