This document discusses the treatment of metabolic acidosis in chronic kidney disease (CKD). It notes that metabolic acidosis is common in advanced CKD, occurring in 30-50% of individuals with eGFR below 30 ml/min/1.73m2. For chronic metabolic acidosis, the recommended approach is oral bicarbonate supplementation. For acute severe metabolic acidosis with a pH below 7.2, hemodialysis or intravenous bicarbonate to raise serum bicarbonate levels above 8 and pH above 7.2 is recommended. The document outlines potential side effects of bicarbonate therapy including increased volume, sodium levels, and intracellular acidosis.

1. Treatment of
Metabolic Acidosis
in CKD
ADE WIJAYA, MD – NOVEMBER 2017

3. Outline:
• Introduction
• Chronic vs Acute severe metabolic acidosis in CKD
• Approach and treatment algorhytm

4. Introduction
Metabolic acidosis is a common complication of advanced CKD
Present in 30-50% of individuals with eGFR <30 ml/min/1.73 m2
It develops mainly secondary to reduced kidney mass and an inability to excrete the daily acid
load via ammoniagenesis
Low serum bicarbonate has been associated with increased mortality in patients with moderate
and advanced CKD
Chen, W., & Abramowitz, M. K. (2014). Treatment of Metabolic Acidosis in Patients With CKD. American Journal of Kidney Diseases : The Official Journal of the National Kidney Foundation, 63(2), 311–317.
http://doi.org/10.1053/j.ajkd.2013.06.017

5. Chen, W., & Abramowitz, M. K. (2014). Treatment of Metabolic Acidosis in Patients With CKD. American Journal of Kidney Diseases : The Official Journal of the National Kidney Foundation, 63(2), 311–317.
http://doi.org/10.1053/j.ajkd.2013.06.017

6. Chen, W., & Abramowitz, M. K. (2014). Treatment of Metabolic Acidosis in Patients With CKD. American Journal of Kidney Diseases : The Official Journal of the National Kidney Foundation, 63(2), 311–317.
http://doi.org/10.1053/j.ajkd.2013.06.017

7. Treatment of severe metabolic acidoses
(pH <7.2)
 Hemodialysis
 Alkaline therapy:
NaHCO3 to get serum HCO3 >8 and pH >7.2
(estimate mmol of HCO3 needed as 8-[HCO3]serum × wt × 0.5)
Side effects: ↑ volume, ↑ Na, ↓ ICa, ↑ PaCO2 (& ∴ intracellular acidosis), overshoot
(Nat Rev Nephol 2012;8:589)

9. Summary
• Acid-Base
• Metabolic acidosis
• CKD
• Chronic vs acute treatment