Hemodialysis for Severe Metabolic Alkalosis: A Comprehensive Review of Current Practices

Metabolic alkalosis is very common in hospitalized patients, and it is due to a negative H+ balance with base gain, especially HCO3-. When metabolic alkalosis is severe (pH ≥7.55) or extreme (pH >7.6), it is associated with extremely high morbidity and mortality, since, in addition to the underlying pathology, alkalemia itself generates serious organic repercussions and must be corrected promptly. Specifically, severe metabolic alkalosis is associated with increased adrenergic sensitivity, ionic hypocalcemia, hypokalemia, neuromuscular complications, myocardial and cerebral ischemia.

This narrative review explores literature reports where renal replacement therapy has been used to control severe metabolic alkalosis. It also analyzes side effects and response to therapy and attempts to provide recommendations regarding how to manage severe metabolic alkalosis with hemodialysis (HD).

In severe and extreme metabolic alkalosis, in addition to diagnosing and treating the underlying cause, it is necessary to promptly remove excess bases, which can be achieved through renal replacement therapy. Intermittent HD with low bicarbonate in the dialysate has proven to be very effective for its management.