Optimal Serum Bicarbonate Management in Dialysis Patients

Target Bicarbonate Level and Monitoring

The American Journal of Kidney Diseases recommends that serum bicarbonate should be maintained at ≥22 mmol/L through regular monitoring and adjustment of dialysate bicarbonate concentration, with measurements obtained at least monthly 1, 2, 3
The evidence-based target for predialysis serum bicarbonate is ≥22 mmol/L, which has been established to prevent multiple complications including bone disease, protein catabolism, and progression of metabolic derangements 1, 2, 3, 4
Patients with normal bone biopsy results have been shown to have serum bicarbonate levels around 23 mmol/L, while those with osteodystrophy have levels below 20 mmol/L 1, 2, 3

Bone disease: Acidosis exaggerates bone dissolution by altering calcium-PTH-vitamin D homeostasis, contributing to renal osteodystrophy and increased fracture risk 1, 2, 3
Protein catabolism: Increased protein breakdown leads to muscle wasting, malnutrition, and negative nitrogen balance 1, 4
Secondary hyperparathyroidism: A study of dialysis patients showed that those with acidosis had progression of secondary hyperparathyroidism over 18 months compared to controls 1, 2, 3

Avoid citrate-containing alkali supplements in dialysis patients exposed to aluminum salts, as citrate increases aluminum absorption both before and during dialysis, potentially worsening bone disease 1, 2, 3, 4
The National Kidney Foundation recommends avoiding citrate-based supplements in patients with potential aluminum exposure 1, 4