Metabolic acidosis and alkali therapy in paediatric kidney transplant recipients

Metabolic acidosis is prevalent in up to 40% of paediatric kidney transplant recipients, in the presence of largely restored kidney function. Despite widespread alkali use, a substantial proportion of treated patients do not achieve the biochemical target, reflecting distinct underlying mechanisms. The benefit of metabolic acidosis correction is plausible, yet high quality data supporting alkali use are lacking. Registry-based evidence demonstrates that metabolic acidosis is independently associated with an increased risk of allograft dysfunction, and persistent acidosis despite alkali use is associated with an inferior outcome. This review makes a case for a patient-centred, proportionate alkali prescribing approach. It describes potential causes of poor metabolic acidosis control despite treatment, including under-dosing, type IV renal tubular acidosis, and non-adherence. A proportionate prescribing framework, informed by metabolic acidosis phenotype, adherence assessment, and dose-response, enables maximum benefit in patients who can respond and therapy simplification in those who cannot.