A 68-year-old man with CKD stage 4 (eGFR 22) and metabolic acidosis (serum bicarbonate 18 mEq/L) is not on oral bicarbonate. According to KDIGO 2022, when should oral bicarbonate supplementation be initiated in CKD?
- A Only when serum bicarbonate falls below 15 mEq/L
- B When serum bicarbonate falls below 22 mEq/L in CKD ✓
- C Only in dialysis patients
- D When urine pH > 6.5
Correct answer: B. When serum bicarbonate falls below 22 mEq/L in CKD
Explanation
KDIGO 2022 CKD guidelines recommend treating metabolic acidosis in CKD patients when serum bicarbonate falls below 22 mEq/L with oral bicarbonate supplementation, targeting a value in the normal range (22-26 mEq/L). This has been shown to slow CKD progression, reduce muscle wasting, and improve bone mineralisation in RCTs including the BASE trial. Waiting until bicarbonate is <15 mEq/L is inappropriate as it allows ongoing harm.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.