Metabolic Acidosis Management in Chronic Kidney Disease

Metabolic acidosis is a common and consequential complication of chronic kidney disease (CKD), arising when diminished nephron function fails to excrete the acid load generated by normal metabolism. The resulting retention of hydrogen ions and decline in serum bicarbonate provoke bone demineralisation, muscle wasting, inflammation and accelerated progression of renal dysfunction. Clinically, persistent acidosis is linked to worsening glomerular filtration rate, increased cardiovascular risk and reduced quality of life. Management strategies centre on alkali therapy—most often oral sodium bicarbonate or citrate salts—to restore acid–base balance, slow structural injury and preserve nutritional status. Dietary interventions that reduce dietary acid load, such as increased fruit and vegetable intake and moderated animal protein consumption, complement pharmacological measures. Treatment targets generally aim for serum bicarbonate in the mid‐normal range, balancing the benefits of acidosis correction against potential sodium-related volume retention and blood pressure fluctuations. Early identification and individualised therapy are essential to mitigate downstream complications, improve patient‐reported outcomes and delay the need for renal replacement therapy.

Research from Nature Portfolio

Recent work in a large pre-dialysis CKD cohort has demonstrated a clear inverse relationship between serum bicarbonate and arterial stiffness, measured by brachial-to-ankle pulse-wave velocity. Participants with bicarbonate below 22 mmol/L exhibited significantly higher pulse-wave velocities, indicating that even moderate acidosis may contribute to vascular dysfunction and elevated cardiovascular risk. These findings underscore acid–base correction not only as a renal protective measure but also as a means of modulating systemic vascular health in CKD.

Metabolic Acidosis Management in Chronic Kidney Disease publication trend

The graph below shows the total number of articles in metabolic acidosis management in chronic kidney disease across all publications each year (not limited to Nature Index journals).

Technical terms

Metabolic acidosis: A state of decreased blood pH due to accumulation of non-volatile acids or loss of bicarbonate, often encountered in CKD when renal acid excretion is impaired.

Serum bicarbonate: The predominant buffer in plasma, typically measured as HCO₃⁻ concentration and used to assess acid–base status.

Estimated glomerular filtration rate (eGFR): A calculated index of kidney filtration function based on serum creatinine, age, sex and sometimes race.

Pulse-wave velocity (PWV): A non-invasive measure of arterial stiffness, determined by the speed of the pressure wave travelling along the vasculature.

Alkali therapy: Administration of bicarbonate or citrate salts to neutralise excess acid and restore physiological pH.

References

1. Metabolic acidosis and the progression of chronic kidney disease. BMC Nephrology (2014).
2. Treatment of metabolic acidosis with sodium bicarbonate delays progression of chronic kidney disease: the UBI Study. Journal of Nephrology (2019).
3. Dietary Treatment of Metabolic Acidosis in Chronic Kidney Disease. Nutrients (2018).
4. Metabolic acidosis is associated with pulse wave velocity in chronic kidney disease: Results from the KNOW-CKD Study. Scientific Reports (2019).
5. Oral Bicarbonate Therapy in Non-Haemodialysis Dependent Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Journal of Clinical Medicine (2019).
6. NaHCO3 loading causes increased arterial pressure and kidney damage in rats with chronic kidney disease. Clinical Science (2024).