Would you add an additional alkali medication for patients with recurrent uric acid nephrolithiasis who are on high doses of potassium citrate and continue to have acidic urine?  

Maybe. My first concern is poor compliance with potassium citrate. I would like to see the patients home pH records. I strongly encourage patients on alkali therapy to test urine pH periodically, and more frequently if a dose adjustment appears to be needed. I prefer potassium citrate to sodium bica...