Oral and iv soda bicarb therapy in CKD? How to manage acidosis in CKD? At what level of bicarb soda bicarb therapy is indicated?

Older adults often have chronic renal disease and metabolic acidosis, but the efficacy of oral sodium bicarbonate treatment in this population is unknown. 

Metabolic acidosis was one of the first problems in individuals with CKD to be discovered and explained pathologically. Despite mounting evidence of acidosis’s harmful effects, acidosis therapy has received little research, particularly conventional clinical results.

What is metabolic acidosis?

Metabolic acidosis is the accumulation of acid in the body as a result of renal disease or failure. When your body fluids include an excessive amount of acid, it implies that your body is either not removing enough acid, producing too much acid, or is unable to balance the acid in your body.

It has been proposed that metabolic acidosis may have a detrimental influence on renal dysfunction development and that sodium bicarbonate treatment may mitigate this effect. However, further research is needed to confirm such a renoprotective approach. The most common buffer used in dialysis fluids is sodium bicarbonate. 

What causes metabolic acidosis?

Kidneys that are in good shape perform a variety of functions. One of these responsibilities is to maintain the proper acid balance in the body. It is accomplished by the kidneys eliminating acid from the body through urine. A build-up of too many acids in the blood causes metabolic acidosis. When your kidneys are unable to eradicate enough acid from your blood, this occurs.

What are the signs and symptoms?

Not everyone will have symptoms or indications. You may, however, encounter the following:

• Deep and long breathes
• Fast heartbeat
• Headache and perplexity
• Weakness
• Tiredness
• Feeling ill to your stomach and vomiting (nausea)
• Appetite loss.

Complications of metabolic acidosis if you have CKD

• Increased bone loss (osteoporosis): Metabolic acidosis can cause you to lose bone. It can put you at risk of breaking key bones like your hips or backbone.
• Renal disease progression: Metabolic acidosis can exacerbate kidney disease. It’s unclear exactly how this occurs. Kidney function deteriorates as acid builds up, and acid builds up as kidney function declines. Kidney disease might worsen as a result of this.
• Muscle loss: Albumin is a protein that helps your body create and maintain healthy muscles. Metabolic acidosis reduces the quantity of albumin produced in the body, resulting in muscle loss, often known as “muscle wasting.”
• Endocrine disorders: Metabolic acidosis impairs your body’s capacity to sustain normal endocrine system activities (the collection of glands that produce hormones). It can lead to insulin resistance (the hormone in your body that helps keep your blood sugar level from getting too high or too low). It can progress to diabetes if left untreated for too long or not addressed promptly.

Metabolic acidosis in CKD Patients:

Patients with CKD have a wide range of abnormalities and impairments, with metabolic acidosis being one of the first consequences to be detected and pathologically described. The drop in GFR correlates with a decrease in serum bicarbonate in typical CKD, which is related to the kidney’s inability to manufacture ammonia, regenerate bicarbonate, and eliminate hydrogen ions. In some instances, acid excretion decreases earlier than expected when GFR declines. Obstructive nephropathy, sickle cell nephropathy, and diabetic CKD are all examples of diseases where this might occur.

Renal Effects of Metabolic Acidosis

Metabolic acidosis appears to have a role in the development of CKD, according to research. An observational study demonstrated the link between metabolic acidosis and deteriorating renal illness in animal models and people. Bicarbonate supplementation has been proven to delay the renal disease in a small number of interventional trials with a variety of patient types.

Even though CKD causes acidosis due to reduced renal ammonia genesis, ammonia output per remaining nephron paradoxically increases as the disease advances.

How to manage acidosis in CKD?

• Sodium Bicarbonate: Bicarbonate (a kind of carbon dioxide) is an essential component of our blood. Low bicarbonate levels in the blood indicate metabolic acidosis. An alkali (also known as base) is the polar opposite of acid and may counteract the acid. Our blood does not get overly acidic as a result of it. Your bicarbonate levels are kept in check by healthy kidneys. Low bicarbonate levels (less than 22 mmol/l) can hasten the progression of renal disease. Treatment with sodium bicarbonate or sodium citrate tablets has been proven in a small number of studies to help prevent the renal disease from worsening. However, it would help if you did not take sodium bicarbonate or sodium citrate tablets unless your healthcare practitioner recommends it.

• Through diet: Increased fruit and vegetable consumption may help to reduce the acid load in the body. Because fruits and vegetables create alkali, whereas meats, eggs, cheese, and cereal grains induce the body to produce acid, this is the case. Depending on your stage of kidney disease, your renal dietitian can teach you how to safely increase the correct types and amounts of fruits and vegetables in your diet.

At what level of bicarb soda bicarb therapy is indicated?

Bicarbonate treatment is suggested for metabolic acidosis at arterial pH levels ranging from 6.9 to 7.2. We recommend that bicarbonate treatment be administered at a pH of 7.0 but that this target pH is used as a guideline that varies based on the clinical situation.