Metabolic Acidosis and Progression of CKD: Current Guidelines and Considerations

Observational evidence suggests that metabolic acidosis in chronic kidney disease (CKD) is a driver of CKD progression, but there remains significant debate regarding the quantity and quality of published evidence to support treatment. The Kidney Disease: Improving Global Outcomes (KDIGO) guidance on metabolic acidosis in CKD highlighted this controversy by publishing practice points, not recommendations, based primarily on placebo-controlled randomized controlled trials. These practice points suggest considering treatment to prevent metabolic acidosis with a proposed cutoff for serum bicarbonate < 18 mmol/L. However, this approach means a substantial number of individuals with CKD may now remain untreated for their metabolic acidosis, which may impact CKD progression with associated adverse health outcomes. Additionally, the guidance does not include all the available evidence. From our critical appraisal we suggest that the evidence cited could have been interpreted differently. We recommend that the practice points published are revised based on critical appraisal of the cited evidence to inform the clinical management of individuals with metabolic acidosis in CKD. We also suggest a research agenda for future studies to help resolve this issue.