Oral alkali therapy and the management of metabolic acidosis of chronic kidney disease: A narrative literature review

Abstract

Chronic metabolic acidosis is a common complication seen in advanced chronic kidney disease (CKD). There is currently no consensus on its management in the Republic of Ireland. Recent trials have suggested that appropriate active management of metabolic acidosis through oral alkali therapy and modified diet can have a deterring impact on CKD progression. The potential benefits of treatment include preservation of bone health and improvement in muscle function; however, present data is limited. This review highlights the current evidence, available primarily from randomised control trials (RCTs) over the last decade, in managing the metabolic acidosis of CKD and outlines ongoing RCTs that are promising. An economic perspective is also briefly discussed to support decision-making.

Oral Bicarbonate Therapy in Non-Haemodialysis Dependent Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

“…Around 45,000 premature deaths are attributed to CKD annually in the United Kingdom [3]. Furthermore, the management of CKD places a substantial economic burden on healthcare systems across the globe, and healthcare expenditure has been noted to be inversely proportional to renal function [4]. The National Health Service (NHS) in England spent approximately £1.45 billion on CKD in 2009–2010 [1].…”

“…Metabolic acidosis is frequently found in CKD patients, and becomes more common with worsening renal function [4]. Metabolic acidosis has been operationalised as serum bicarbonate levels that are consistently below 22 mmol/L [4,5,6].…”

“…Metabolic acidosis has been operationalised as serum bicarbonate levels that are consistently below 22 mmol/L [4,5,6]. It is associated with other pathophysiological changes including systemic inflammation, upregulation of parathyroid hormone receptors in osteoblasts and increased activity of osteoclasts; which leads to accelerated bone resorption and osteopenia, reduction of Na + -K + -ATPase activity in erythrocytes—resulting in impairment of myocardial contractility and heart failure, and reduced respiratory reserve and exhaustion of body buffer systems, which increases severity of acute intercurrent illnesses [4,5,6,7,8,9,10]. The degree of metabolic acidosis is directly associated with glomerular filtration rate GFR, and is due to the failure of the kidneys to produce ammonia, regenerate bicarbonate and excrete hydrogen ions [11].…”

Bicarbonate Therapy for Critically Ill Patients with Metabolic Acidosis: A Systematic Review

“…Buffers are substances that counteract changes in pH [9], and sodium bicarbonate is the most frequently used buffer [30][31]. The main reason to commence sodium bicarbonate therapy is to prevent or reverse the effects of metabolic acidemia, especially in the cardiovascular system [25].…”

The effect of sodium bicarbonate administration on renal function: A systematic review and meta-analysis of clinical trials

“…Sodium bicarbonate is a major component of alkali therapy (5), where previous studies have shown that there is an inverse association between sodium bicarbonate administration and acidosis (6,7). Also, sodium bicarbonate therapy has a signi cant increasing effect on serum bicarbonate level (8), thereby conferring a bene cial effect on the bicarbonate buffer system (9).…”