Metabolic acidosis: Difference between revisions

== Consequences ==

 

Acute Metabolic Acidosis most often occurs during hospitalizations, and acute critical illnesses. It is often associated with poor prognosis, with a mortality rate as high as 57% if the pH remains untreated at 7.20.<ref name="Treatment of acute metabolic acidos">{{cite journal |last1=Kraut |first1=Jeffrey A. |last2=Madias |first2=Nicolaos E. |title=Treatment of acute metabolic acidosis: a pathophysiologic approach |journal=Nature Reviews Nephrology |date=4 September 2012 |volume=8 |issue=10 |pages=589–601 |doi=10.1038/nrneph.2012.186|pmid=22945490 |s2cid=34657707 }}</ref> At lower pH levels, acute metabolic acidosis can lead to impaired circulation and end organ function.

 

Chronic metabolic acidosis commonly occurs in people with Chronic Kidney Disease with an eGFR of less than 45 ml/min/1.73m², most often with mild to moderate severity; however, metabolic acidosis can manifest earlier on in the course of Chronic Kidney Disease. Multiple animal and human studies have shown that metabolic acidosis in Chronic Kidney Disease, given its chronic nature, has a profound adverse impact on cellular function, overall contributing to high morbidities in patients.

 

Treatment of metabolic acidosis depends on the underlying cause, and should target reversing the main process. When considering course of treatment, it is important to distinguish between acute versus chronic forms.

 

Bicarbonate therapy is generally administered In patients with severe acute acidemia (pH < 7.11), or with less severe acidemia (pH 7.1-7.2) who have severe acute kidney injury. Bicarbonate therapy is not recommended for people with less severe acidosis (pH ≥ 7.1), unless severe acute kidney injury is present. In the BICAR-ICU trial,<ref name="BICAR-ICU 2018">{{cite journal |last1=Jaber |first1=Samir |last2=Paugam |first2=Catherine |last3=Futier |first3=Emmanuel | display-authors=etal |title=Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial |journal=The Lancet |volume=392 |issue=10141 |pages=31–40 |language=en |doi=10.1016/S0140-6736(18)31080-8 |pmid=29910040 |date=2018|s2cid=49276138 |url=https://hal.umontpellier.fr/hal-01818634/file/2018%20Jaber%20et%20al.%20Sodium%20bicarbonate%20therapy.pdf }}</ref> bicarbonate therapy for maintaining a pH >7.3 had no overall effect on the composite outcome of all-cause mortality and the presence of at least one organ failure at day 7. However, amongst the sub-group of patients with severe acute kidney injury, bicarbonate therapy significantly decreased the primary composite outcome, and 28-day mortality, along with the need for [[kidney dialysis|dialysis]].

 

For people with Chronic Kidney Disease, treating metabolic acidosis slows the progression of chronic kidney disease.<ref>{{Cite journal|last1=Goraya|first1=Nimrit|last2=Wesson|first2=Donald E.|title=Clinical evidence that treatment of metabolic acidosis slows the progression of chronic kidney disease|journal=Current Opinion in Nephrology and Hypertension|language=en-US|volume=28|issue=3|pages=267–277|doi=10.1097/MNH.0000000000000491|pmid=30681417|pmc=6467553|issn=1062-4821|year=2019}}</ref> Dietary interventions for treatment of chronic metabolic acidosis include base-inducing fruits and vegetables that assist with reducing the urine net acid excretion, and increase TCO2. Recent research has also suggested that dietary protein restriction, through ketoanalogue-supplemented vegetarian very low protein diets are also a nutritionally safe option for correction of metabolic acidosis in people with Chronic Kidney Disease.<ref>{{Cite journal|last1=Garneata|first1=Liliana|last2=Stancu|first2=Alexandra|last3=Dragomir|first3=Diana|last4=Stefan|first4=Gabriel|last5=Mircescu|first5=Gabriel|date=2016-07-01|title=Ketoanalogue-Supplemented Vegetarian Very Low–Protein Diet and CKD Progression|journal=Journal of the American Society of Nephrology|language=en|volume=27|issue=7|pages=2164–2176|doi=10.1681/ASN.2015040369|issn=1046-6673|pmid=26823552|pmc=4926970}}</ref>