We discussed a fascinating article from KI at Journal Club this week. It sheds some light on metabolic acidosis in CKD patients. As we all know metabolic acidosis can cause symptoms and in some studies worsens the progression of CKD. It also leads to Malnutrition Inflammation syndrome.
Few papers early in the 1990s showed that if you keep the ph >7.4, there might be hastening of the renal injury. It never cought on the renal community probably for two reasons: NaHCo3- people thought might worsen the HTN of the patient. Na citrate might not be a good combination with then used aluminium binders.
This study ( although small ) with 30-40 patients ( only HTN nephropathy) showed that the rate of GFR decline was slower in the Na citrate treated group after 30 months of treatment. What showed statistical significance was eGFRcys and Pcys and eGFRcrt and Plasma Crt were almost reaching significance but didn't. At 6 months, there was no difference. SBP was not different at 6 months and 30 months in both groups. The bicarbonate differnce was 19 vs 23. They hence suggest keeping bicarbonate >22 with help of Na citrate.
1. NaHC03 can also be used. The NACL is what really causes worsening HTN for two reasons, one because of the ECF distribitution of NAHC03 is not as great as NACL. Second, the macula densa really senses Cl and not Na and if you think about it, HTN is more of a CL related problem and not Na.
2. This article touches on a pathophysiology of endothelin. When there is renal injury endothelin in the kidney is produced that can cause more damage. So in summary, CKD can lead to Metabolic acidosis.
Metabolic acidosis on one hand can cause increase kidney H+ and that causes increase endothelin which via ETA receptors leads to IF/TA and via ETB receptors to proximal and distal H secretion to mitigate the metabolic acidosis. On the other hand, this metabolic acidosis leads to increased ammonium production that leds to complement activation and IF/TA and worsening of the CKD.
3. So aggresively treating the Metabolic acidosis with simple and cheap medications like Nacitrate or Na HCO3 might be helpful.
4. Small study, need larger studies to confirm this as it might not be significant when we bring in Diabetics, other GNs and other CKD patients. at this point, KDOQI does recommend to keep Bicarb around 22 in CKD 3,4,5 and ESRD patients.
A few more references:
Friday, April 30, 2010
JOURNAL CLUB: Metabolic Acidosis and improving GFR
Posted by Kenar D Jhaveri( kidney 007) at 8:36 AM
Labels: CKD and ESRD, electrolytes, journal club
Subscribe to: Post Comments (Atom)
- ► 2022 (18)
- ► 2021 (36)
- ► 2020 (32)
- ► 2019 (42)
- ► 2018 (57)
- ► 2017 (52)
- ► 2016 (45)
- ► 2015 (63)
- ► 2014 (95)
- ► 2013 (133)
- ► 2012 (201)
- ► 2011 (370)
- JOURNAL CLUB: Metabolic Acidosis and improving GFR
- The Online Transplant Center: Kidney Biopsy in Hea...
- Kidney Biopsy in Heart Transplant Candidates?
- TOPIC DISCUSSION: Cellular Senescence and Renal Aging
- CLINICAL CASE 12
- CLINICAL CASE 11
- IN THE NEWS ---> Vancomycin and the kidney
- TOPIC DISCUSSION: Smoking and Kidney Disease
- The Online Transplant Center: Dual Liver and Kidne...
- The Online Transplant Center: HIV and the Kidney T...
- The Online Transplant Center: Obesity and Kidney T...
- Dual Liver and Kidney Transplantations
- HIV and the Kidney Transplant
- Obesity and Kidney Transplantation
- In the News: ASN website for Renal Fellows
- TOPIC DISCUSSION: Adolescents and Disease
- TOPIC DISCUSSION: Why do AVG and AVF get stenosis?
- NKF reports
- CONSULT ROUNDS
- TOPIC DISCUSSION: Asymptomatic Hyponatremia
- IN THE NEWS- RENAL ANGINA SYNDROME
- CLINICAL CASE 10, ANSWER AND SUMMARY
- TOPIC DISCUSSION: PHOSPHATE BINDERS
- TOPIC DISCUSSION: A rare case of statin induced rh...
- IN THE NEWS: GLOSEN Study
- IN THE NEWS: Dialysis Time
- TOPIC DISCUSSION: Albuminuria and Proteinuria
- The Online Transplant Center: Antibody Mediated Re...
- Antibody Mediated Rejection Review
- The Online Transplant Center: Bone marrow transpla...
- Bone marrow transplantation and solid organs
- IN THE NEWS: Tyrosine Kinase Inhibitors and CKD
- IN THE NEWS- MORE NEPHROLOGY CONSULTS
- ▼ April (33)
A similar study was conducted in the UK in 2009 with the same results (http://blog.ecu.edu/sites/nephrologyondemand/?p=971). In fact, our fellows are, collectively, conducting a similar study here at East Carolina University. We weren't sure if the UK data would be applicable to our patient population (eastern North Carolina). Also, it is interesting that other data do not show a difference in alkaline effects with Na-citrate vs. Na-bicarbonate. perhaps this is because they equally increase the strong ion difference. I know the strong ion theory is catching on very slowly in the Nephrology community, but I thought i'd throw it out there for discussion.ReplyDelete
Correct me if I'm wrong, but I believe the volume of distribution of NaHCO3 in the absence of acidosis is larger then NaCl... this is in reference to the first point...ReplyDelete
Yes, thats why it doesn't cause that much HTN as NACLReplyDelete