Letter to the Editor—Reply

We thank the author for their interest in our manuscript, and we acknowledge their concerns regarding the potential downstream effects of elevated sodium intake in our alternate alkali (AA) patients. While we agree that the recommendation of a low sodium diet (≤2300 mg daily) is frequently offered to nephrolithiasis patients for conservative dietary management due to concern for the correlation between increased sodium intake and hypercalciuria, the two prospective studies in which low sodium diet was correlated to decreased urine calcium were performed in hypercalciuric patients with elevated baseline 24-hour urine sodium. ^, This is reflected in the AUA Medical Management of Kidney Stones Guidelines which recommend limited sodium intake for patients with calcium stones and relatively high urinary calcium, as well as for patients with cystine stones. As demonstrated in our Table 2, our patient population predominantly had normal urine calcium and sodium, and therefore the administration of sodium bicarbonate (NAB) in these patients did not contradict the guidelines. In fact, the lack of hypercalciuric effect from 60 mEq/day NAB has been demonstrated previously in a prospective RCT. Moreover, there exists some evidence which suggests that sodium supplementation in hypocitraturic patients actually decreases calcium oxalate supersaturation by improving fluid intake and urine volumes.