Patient-to-Patient Information page
How to measure urinary pH
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Case History Mr D
For measuring urinary pH, I opted to use Johnson Comparator pH Test Papers which are available inexpensively (about £6 for 10 books) from some high street pharmacies, or by mail order from several Internet-based retailers [4]. These test papers are available in various pH ranges; I found the most suitable range was “pH 5.2 – 6.7”. N.B. One only needs to use a small, torn-off piece of paper strip for each test, so a book of papers will last for a long time. An alternative approach would be to conduct the measurements with a battery-powered electronic pH meter of the type often used for measuring soil pH. These are available for around £10 - £30 from gardening centres or from amazon.co.uk on the Internet.
Case History Mr G
I first tried to measure urine pH using the paper pH test strips, but did not like it – it was often difficult to match colours. I purchased a digital pH meter on the Internet from Amazon (http://www.amazon.co.uk/). Several models are available with the price starting from £28. You need to calibrate the meter from time to time (and to do that buy the buffer solutions, unless those are included), but it is not very difficult.
How to obtain Potassium Citrate
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Case History Mr D
Although potassium citrate is available specifically for this purpose in some countries (e.g. the USA) in wax-coated, slow-release capsule form [2], it was found that this form of the medication is difficult to obtain in the UK, is extremely expensive and is not offered on prescription by the NHS. A suitable alternative is potassium citrate mixture, containing 3g of potassium citrate per 10 ml of solution. This preparation is available over the counter at high street pharmacies in 200 ml bottles, or by mail order at a discounted price (around £1 per bottle) from several Internet pharmacies in the UK [3]. If the patient qualifies for free NHS prescriptions, the medication can be prescribed by the GP; otherwise it is probably more cost-effective to buy it at the retail price.
Case History Mr G
I am using Potassium Citrate Mixture in 200ml bottles which I buy on the Internet from the company called Pharmacy2U (http://www.pharmacy2u.co.uk/). The price of a single bottle is £1.79 (March 2010). I usually buy 12 bottles – it is a standard package.
The bottle has a screw cap which can be used as a convenient measure – its volume is exactly 10ml. I usually take Potassium Citrate twice a day, 2 to 2.5 caps (20 - 25ml). This brings my average daily consumption to 40 - 50ml, so a bottle of Potassium Citrate lasts me for 4-5 days.
How to determine the best dose of Potassium Citrate
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Uric acid stones will tend to increase in size when urinary pH drops below 5.5 and will dissolve when the pH rises significantly above 6. The ideal urinary pH for patients with kidney stones is between 6.5 and 7, but there are daily variations in urinary pH, related to the time of day, hydration, and dietary intake. It is helpful, therefore, to check urinary pH at several consistent times during the day to determine whether the dose of medication is having the desired effect.
Case History Mr D
The recommended adult dosage of potassium citrate mixture, according to the label on the bottle, is two teaspoonsful (10 ml) of mixture in plenty of water, thrice daily. I began the titration by taking half this dosage, progressively working up to a level which resulted in a constant urinary pH of 6.5 6.7. Before commencing treatment, my urinary pH had been typically around 5.2 5.4 in the morning, but somewhat higher later in the day. After about two weeks of experimentation, I arrived at a dosage of 1.5 teaspoonsful (7.5 ml) of mixture taken thrice daily to maintain the desired urinary pH level. It was noted that the diurnal variations in pH were also evened out.
Case History Mr G
I try to monitor the pH of my urine 2-3 times a day and to keep it ideally between 6.2 and 7.0. I always take one dose of Potassium Citrate in the morning. Usually I take the second dose in the early evening, but I try to make it adaptive by taking into account the pH reading. I may delay or reduce the second dose if the reading is reasonably high. However, sometimes I may take additional 10-15 ml of Potassium Citrate in the middle of the day or before I go to bed if I see a very low reading (below 5.5). In my case low readings are usually observed early in the morning and after a good physical exercise.
The effect of changing urinary pH on kidney stone formation
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Case History Mr D
The onset of stone disease for this man occurred at 61 years of age, in early 2006, when he presented to his General Practitioner complaining of severe, colic-type pain in the left kidney area. His general state of health was poor and an emergency blood test revealed a seriously elevated serum creatinine level of 647 umol/litre. He was immediately admitted to hospital for further investigations. KUB X-rays and a CT scan demonstrated the presence of several stones in the left kidney, one of which was causing an obstruction of the left ureter, leading to acute renal failure. The radiography also disclosed that the patient had only a single functioning kidney (the left); the right kidney was rudimentary and ineffective. The consultant renal physician suspected that this condition had existed since early childhood, and possibly from birth. The patient subsequently received surgical treatment for fragmentation and removal of the stones by uretero-renoscopy and holmium laser lithotripsy.
Following this initial episode, the patient became a persistent and frequent stone-former. Between February 2006 and September 2009 he required hospital admission on seven occasions (twice via the Emergency Room) for fragmentation and removal of stones by uretero-renoscopy with basket and/or laser lithotripsy. Additionally, he spontaneously passed numerous small stones in the urine throughout 2007 and 2008.
Initially, stone analysis disclosed the presence of calcium oxalate and the patient was started on bendroflumethiazide (2.5 mg daily). This therapy had no measurable effect and the patient continued to form stones. Although the patient denied any history of gouty arthritis, latterly further stone analysis suggested uric acid or mixed uric acid/calcium oxalate stone composition.
Following the last clearance of stones by holmium laser in August/September 2009, Mr D was started on oral treatment with potassium citrate mixture with the purpose of raising his urinary pH [1], which was in the range of 5.2 - 5.4 prior to commencement of treatment. The patient was instructed to monitor his urinary pH, titrating it by dosage adjustment to a level between 6.0 and 7.0. After two weeks of experimentation with the dosage, the patient arrived at a daily oral dose of 60 mEq of potassium citrate (taken in thrice-daily schedule). A fairly stable urinary pH of 6.5 - 6.7 was reported whilst this dosage was maintained.
To present date (May 2010), since the initiation of potassium citrate treatment the patient has formed no further stones and a KUB CT scan in mid-March 2010 demonstrated that his kidney and ureter were stone-free.
Case Study Mr G
(Mr G underwent ESWL and two keyhole procedures (percutaneous nephrolithotomy) for large volume kidney stones that reformed rapidly.) ‘Since I started using Potassium Citrate all unpleasant symptoms of kidney stones quickly disappeared.’
What to Expect with a Laparoscopic Partial Nephrectomy
Case History of Mrs G
PRE-OPERATIVELY
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Background
Being told that you need an operation is anxiety producing. Being told that you need a major operation really does set your mind racing. For me being told that I needed a major operation came like a bolt out of the blue.
First Consultation
This was the first opportunity I had to listen to the facts. It was only at this point could I begin to unpick the scenario I found myself in. I often viewed myself as a bystander rather than the principal actor. This is a coping strategy I have adopted on previous occasions. However, it can lead to people assuming that you are not engaged with the process. They then helpfully, or so they think, impart all their experiences of operations in order to soothe your journey. Some of this ministering was helpful, much was not. The information imparted to me at times took on a surreal quality. Dealing with other people’s reactions e.g. family, friends and work colleagues was a complex minefield which felt claustrophobic at times. The opportunity to discuss in depth with an expert such as Mr Keeley provided a sanctuary and an antidote to the lay ministering of my kith and kin. Despite the obvious anxiety, I felt that control of the situation had been regained. During the consultation facts were imparted with calm honesty and my options were outlined. I expressed the need to feel absolutely certain that my operative procedure was essential. It was agreed to repeat my CT Scans. I felt comfortable and reassured with this. The possibility that the cyst in my kidney was cancerous was broached. From the moment this word was spoken I felt more convinced that an operative procedure was the best route.
Second Consultation
This provided an opportunity to discuss the results of my most recent CT scans. My husband accompanied me. Often at consultations where important information is being shared you fail to hear key pieces, another set of ears is very useful for filling in the gaps! Surgery booked. This all seemed very matter of fact. Decision made: time to get the job done.
Waiting for something is never easy. You are never completely at ease, always on edge. Forgetting and then suddenly remembering what is to come. This was definitely one of the hardest things to overcome. I was very open about my impending surgery and the reason why. However this was a double edged sword. The whole world has a story to tell it would seem about operative procedures good and bad. I also committed the cardinal sin of accessing the internet to elicit those nuggets of information which I felt had been denied to me. This too proved to be only limited in its use. The internet is vast reserve of uncensored information. I was overwhelmed. The information obtained left me one minute comforted and the next wrought with uncontained anxiety. I concluded that I had had the best advice based upon the current evidence available at the time.
I must confess to having a few tearful moments but these were mitigated by the support obtained from family, friends and work colleagues. Talking really can help but only if the listener does just that and suppresses their urge to share their own harrowing experience! I was lucky to be at work right up until the Friday before my operation on the Monday. I had little to time to dwell on probables I was more focussed upon the practical elements such as food shopping, washing, cleaning and ironing to ensure that my children had clothes to wear and food to eat! Having a packed bag for my hospital stay had alarming parallels with my only other hospital experience: child birth. My ability to return to work within a quick time frame dominated my thoughts. With the beauty of hindsight I now recognise that this was an attempt to hold on to my current construct of normality where there was routine and focus to my day. My course of my current journey was alien to me.
Day before operation
This time had a surreal quality where all tasks undertaken e.g. cooking dinner, took on a heightened sense of normality. I had schooled myself into thinking that post operative these would be the chores, that not only would I not be able to do but I also, secretly wouldn’t miss for while either. I felt that I was being treated as “special” by family and friends. They were more fretful than I was. I felt confident about the operation and at no time did I think I did not want it done. I had chosen my path and focussed my mind accordingly. However, this did involve not giving a great deal of thought to the procedure itself. I can only contribute this to my experience as a nurse. Consequently I was aware of the basic procedures that would take place. However, I did read the accompanying literature about my stay in hospital avidly. I had little trouble sleeping: I was mentally and physically exhausted. The abiding emotion I did feel when I allowed myself to engage with the process was an overwhelming sense of loneliness. The support and succour of others is no lasting counter to this. When the chips were down, I was on my own. It was at this point that I put my complete faith and confidence in the medical staff. There was no turning back.
OPERATION
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Day of Operation
The drive to the hospital early in the morning left some time for reflection but an abiding sense of wanting to get it over and done with. The procedure I was booked for was a laparoscopic partial nephrectomy. I had been informed, and read that post operative recovery from such a procedure was more likely to be quicker and less eventful that more traditional approaches. Confidence in the surgeon is paramount and I felt I was in expert hands. This allayed my anxiety but did not eliminate it completely. The process of agreeing and signing the consent form was more traumatic for my husband than it was for me: after all I would be oblivious to it all once the anaesthetic kicked in. Admitting to the anaesthetist that I was more anxious and fearful than I possibly appeared allowed her to ensure that pre operative medication could be tailored accordingly. Being told to change into my operation gown felt like relinquishing control and in a way I was. My last conscious memory was being wheeled into the anaesthetic room some four or so hours later my first memory was making out the time on the clock opposite my hospital bed. I vividly remember it was 12:50 and apart from feeling sleepy, I felt remarkably well. No nausea, no sickness and hardly any pain. I had acquired a catheter and wound drain, some simple dressings and an intravenous drip. Although necessary, the latter proved to be more of an inconvenience to my recovery as they hampered my craving to regain my independence. Patience has never been a virtue of mine. By the time Mr Keeley arrived to discuss the finer points of my operation, I had been sat out of bed for a couple of hours. Nevertheless, I remembered nothing of the ensuing discussion as I promptly fell asleep. Good job my husband was there to fill me in when I came round again.
The two days immediately post operation were uneventful but nonetheless remarkable for the fact that I felt so well. I felt euphoric for the first 24 hours. This may have been attributed to the anaesthesia and subsequent analgesia. Whatever the reason, I didn’t care, I felt generally very well. Drip, drain and catheter were dispensed with such rapidity I began to reflect that I had not had an operation at all. This sense was compounded by my visitors, nursing staff and even the medic who came to take my blood on the morning after my operation. They voiced their disbelief that I had been through a major procedure as I appeared so well. In fact I felt so well that I was discharged from hospital a day earlier than planned. I had spent a whole two days in hospital including the time taken for my operation – I felt that this was truly incredible.
POST-OPERATION
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Recovery at Home
Being at home away from the security and enforced rest that hospital affords had its challenges. While I continued to make a good recovery, I felt an overwhelming urge to resume normal activities. It must be said that post operative recovery is full of milestones. I had overcome some of the major hurdles such as the actual operation but the enforced, more sedentary pace of life would be, or so I thought, more difficult to endure. I had imagined the weeks of my recovery to be some kind of penance to be endured with stoicism and grace. After all I was used to a busy pace of life with a full time demanding job, two teenage children, a husband who was frequently away from home working and numerous small rodents to care for, not to mention a very active Springer Spaniel who couldn’t quite comprehend my sudden inaction! On reflection, I spent my first few weeks feeling too exhausted to even think about my normal life pre op. I found myself often intending to do things but often waking up an hour later having forgotten what it was I was going to do anyway.
By week two I felt well enough to attempt a short dog walk but I was shocked by how exhausted, and even out of breath I felt upon ascending a moderate incline. Never have I been more glad of a boisterous spaniel and his propensity to pull on the lead. I suppose the most frustrating part was that my memory appeared to be impaired – I hoped that this would be a temporary state of affairs.
Gradually I began to undertake normal activities such as household chores. I did not feel that I wanted to drive and was happy to be driven. It was quite a novelty to be accompanied to the weekly shop by my husband who had hitherto abandoned this necessary chore some years previously. However, I yearned to regain my ability to shop independently! Some three weeks after my operation I felt motivated to drive and more importantly felt well enough and safe enough to drive. Although I only undertook short journeys at first, it felt so liberating. I had taken another step towards normality.
My confidence and my capacity to undertake usual activities continued to accelerate. Nevertheless, I knew that I wasn’t ready to return to work. My concentration levels and ability to recall things quickly still felt sluggish. Whenever I had had time to myself in the past I had enjoyed the guilty pleasure of reading novels, magazines and generally just indulging myself. However, I felt unable to read a book as I found myself reading the same words repeatedly which spoilt any potential enjoyment as I could never follow the plot. Rather than feel frustrated by this I busied myself by being creative and completing sewing projects which had been commenced several years earlier. I even felt a sense of satisfaction when I completed a quilt for my daughter’s bedroom.
At the point where I found myself feeling more alert, and more importantly not dozing off to sleep in the middle of the afternoon, I considered the prospect of returning to work. This was seven week post operation. It was quite daunting at first but as I work in a supportive environment, there was no pressure to rush back into the full onslaught.
I accepted a phased return to work. This was daunting as I felt that my absence had contributed to a certain amount of “brain fade”. Would I be able to function with the competence that the job demanded? While my cognition had been lethargic during the early post operative period, I know recognise that some of the latter mental sluggishness is due more to lack of use than permanent impairment.
Concluding Thoughts
I can only be positive about my experience of having the procedure I did. While it would be better not have gone down that route at all, that is not have a growth in my kidney that needed to be removed, I can honestly conclude that I feel none the worse for my experience. On the contrary, I feel reassured that in expert hands you can have a good operative experience. The most irksome features of the process, which I have omitted to mention previously as they were fleeting, were the shoulder tip pain and abdominal bloating suffered consequent to the laparoscopic method used. Contrary to the portrayal of medical scenarios acted out in hospital dramas, modern surgery is it would seem is cutting edge and slick. Without engaging in an extended exposition of hyperbole regarding the skill of Mr Keeley and his team, I feel that my abiding testimony would be that I would recommend this procedure, without hesitation, to any one faced with a dilemma similar to my own.