From the Guidelines
Treatment for low bicarbonate levels should aim to maintain serum bicarbonate at or above 22 mmol/L through oral supplementation with bicarbonate salts, such as sodium bicarbonate, at a dose of 2 to 4 g/d or 25 to 50 mEq/d. This approach is supported by the clinical practice guidelines for nutrition in chronic renal failure 1. The goal of treatment is to correct metabolic acidemia, which is associated with increased oxidation of branched chain amino acids, protein degradation, and decreased albumin synthesis.
Key considerations in treating low bicarbonate levels include:
- Monitoring serum bicarbonate levels regularly, at monthly intervals, to assess the need for correction 1
- Using higher dialysate bicarbonate concentrations, such as 38 mmol/L, in hemodialysate to safely increase predialysis serum bicarbonate concentrations 1
- Oral sodium bicarbonate supplementation as an effective means to increase serum bicarbonate concentrations 1
- Potential benefits of correcting acidemia, including increased serum albumin, decreased protein degradation rates, and increased plasma concentrations of branched chain amino acids 1
It is essential to address the underlying cause of metabolic acidosis, such as managing kidney disease or controlling diabetes, while supporting the body's acid-base balance. Dietary modifications, including consuming more fruits and vegetables, may also be beneficial. However, the primary focus should be on maintaining adequate serum bicarbonate levels through supplementation and dialysate adjustments, as recommended by the guidelines 1.
From the FDA Drug Label
Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis.
Treatment of low bicarb (metabolic acidosis) should be done with sodium bicarbonate (IV), and it is indicated to minimize risks inherent to the acidosis itself. The treatment should, if possible, be superimposed on measures designed to control the basic cause of the acidosis.
- Key points:
- Sodium bicarbonate therapy is used to treat metabolic acidosis.
- It is indicated in cases where a rapid increase in plasma total CO2 content is crucial.
- Treatment should be accompanied by measures to control the basic cause of the acidosis. 2
From the Research
Bicarb Low Treatment
- The treatment of metabolic acidosis with bicarbonate is a controversial topic, with some studies suggesting limited benefit for patients with severe metabolic acidosis 3, 4.
- However, bicarbonate therapy may be beneficial for patients with accompanying acute kidney injury 4.
- The administration of bicarbonate should be individualized, and the amount given should be calculated to bring the pH up to 7.2 3.
- The use of sodium bicarbonate to treat metabolic acidosis is associated with potential side effects, including hypercapnia, hypokalemia, ionized hypocalcemia, and QTc interval prolongation 5.
- Treatment of metabolic acidosis with sodium bicarbonate may delay the progression of chronic kidney disease, as shown in the UBI Study 6.
Indications for Bicarb Low Treatment
- Chronic bicarbonate replacement is indicated for patients who continue to lose bicarbonate in the ambulatory setting, particularly patients with renal tubular acidosis syndromes or diarrhea 3.
- Bicarbonate therapy may be beneficial for patients with acute lactic acidosis and ketoacidosis, as lactate and ketone bodies can be converted back to bicarbonate if the clinical situation improves 3.
- Patients with advanced chronic kidney disease may benefit from sodium bicarbonate administration to attenuate the negative impact of metabolic acidosis on kidney function 5.