From the Guidelines
To treat metabolic alkalosis, the most effective approach is to replace fluid and electrolyte losses with intravenous normal saline solution and consider potassium chloride supplementation, as evidenced by the latest guidelines 1. When managing metabolic alkalosis, it's crucial to identify and address the underlying cause. The treatment should focus on restoring normal acid-base balance and electrolyte levels.
- Replace fluid losses with intravenous normal saline solution, particularly if vomiting or diuretic use is the cause.
- Consider potassium chloride supplementation (typically 40-80 mEq/day orally or 10-20 mEq/hour IV for severe cases) as potassium deficiency often accompanies metabolic alkalosis.
- In cases of severe chloride depletion, ammonium chloride (100-200 mg/kg/day divided into doses) might be administered.
- Acetazolamide (250-500 mg orally 1-4 times daily) can help by increasing bicarbonate excretion in the urine, as suggested in the KDIGO 2021 clinical practice guideline for the management of glomerular diseases 1. The use of loop diuretics, such as frusemide, should be cautious, as high doses can lead to severe electrolyte disturbances and metabolic alkalosis, as noted in the guidelines on the management of ascites in cirrhosis 1. However, the most recent and relevant guideline for managing complications of glomerular disease, including metabolic alkalosis, is the KDIGO 2021 guideline 1, which recommends the use of loop diuretics as first-line therapy for edema, with careful monitoring for adverse effects.
From the Research
Treatment of Metabolic Alkalosis
The treatment of metabolic alkalosis depends on the underlying cause of the disorder. According to 2, 3, 4, 5, 6, the following are key points to consider:
- Reversing the contributory factors that are promoting the alkalosis is crucial in treating metabolic alkalosis.
- Administration of sodium and potassium chloride can form a substantial part of therapy, especially in cases of hypochloremia and hypokalemia 2, 6.
- In severe cases, therapy may include administration of carbonic anhydrase inhibitors, acid infusion, and low bicarbonate dialysis 3, 5.
- Correction of existing depletions and prevention of further losses is essential in treating metabolic alkalosis 6.
- Infusion of potassium chloride can restore the excretion of bicarbonate by the kidney in vomiting-induced chloride depletion alkalosis 6.
Key Considerations
When treating metabolic alkalosis, it is essential to consider the following:
- The underlying cause of the disorder, such as vomiting, diuretic use, or mineralocorticoid excess 2, 3, 4, 5, 6.
- The presence of hypokalemia, hypochloremia, or hyperaldosteronism, which can maintain metabolic alkalosis 3, 5, 6.
- The evaluation of volemic status and measurement of urinary Cl- and plasma levels of renin and aldosterone to identify the cause(s) of metabolic alkalosis 6.