Abstract
Risks of chronic metabolic acidosis in patients with chronic kidney disease. Metabolic acidosis is associated with chronic renal failure (CRF). Often, maintenance dialysis therapies are not able to reverse this condition. The major systemic consequences of chronic metabolic acidosis are increased protein catabolism, decreased protein synthesis, and a negative protein balance that improves after bicarbonate supplementation. Metabolic acidosis also induces insulin resistance and a decrease in the elevated serum leptin levels associated with CRF. These three factors may promote protein catabolism in maintenance dialysis patients. Available data suggest that metabolic acidosis is both catabolic and anti-anabolic. Several clinical studies have shown that correction of metabolic acidosis in maintenance dialysis patients is associated with modest improvements in nutritional status. Preliminary evidence indicates that metabolic acidosis may play a role in beta2-microglobulin accumulation, as well as the hypertriglyceridemia seen in renal failure. Interventional studies for metabolic acidosis have yielded inconsistent results in CRF and maintenance hemodialysis patients. In chronic peritoneal dialysis patients, the mitigation of acidemia appears more consistently to improve nutritional status and reduce hospitalizations. Large-scale, prospective, randomized interventional studies are needed to ascertain the potential benefits of correcting acidemia in maintenance hemodialysis patients. To avoid adverse events, an aggressive management approach is necessary to correct metabolic acidosis. Clinicians should attempt to adhere to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines for maintenance dialysis patients. The guidelines recommend maintenance of serum bicarbonate levels at 22 mEq/L or greater.
Highlights
Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center; and the David Geffen School of Medicine at UCLA and UCLA School of Public Health, Los Angeles, California
Uncorrected metabolic acidosis is detrimental to the nutritional status, may aggravate bone disease and, may impact the overall health of maintenance hemodialysis patients
A small, persistent decrease in the rate of protein synthesis, or increase in protein degradation, could result in a substantial loss of muscle mass and development of more severe chronic bone disease, such as that seen in patients with chronic renal failure (CRF) and end-stage kidney disease
Summary
Metabolic acidosis is associated with chronic renal failure (CRF). Metabolic acidosis induces insulin resistance and a decrease in the elevated serum leptin levels associated with CRF. These three factors may promote protein catabolism in maintenance dialysis patients. Several clinical studies have shown that correction of metabolic acidosis in maintenance dialysis patients is associated with modest improvements in nutritional status. Advanced chronic renal failure (CRF) often results in metabolic acidosis, a process that promotes an increase in hydrogen ions in the body. Many epidemiologic studies on patients undergoing maintenance dialysis have indicated a paradoxically inverse association between mildly decreased serum bicarbonate and improved markers of protein-energy nutritional state. This review will discuss the risk of chronic metabolic acidosis in patients with CRF, with regard to its effect on nutritional status and bone metabolism
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