Metabolic Acidosis in CKD: How Bicarbonate Therapy Slows Kidney Decline

Dec, 2 2025

What Is Metabolic Acidosis in Chronic Kidney Disease?

Metabolic acidosis happens when your blood becomes too acidic because your kidneys can’t remove enough acid or make enough bicarbonate to balance it. In people with chronic kidney disease (CKD), this isn’t rare-it’s common. By stage 3, about 15% of patients have it. By stage 5, nearly half do. Your kidneys normally filter out acid and keep bicarbonate levels steady. But when kidney function drops below 30%, that system breaks down. The result? Blood bicarbonate falls below 22 mEq/L, and pH dips under 7.35. Left untreated, this doesn’t just cause fatigue or muscle weakness-it speeds up kidney damage, weakens bones, and increases heart risks.

Why Bicarbonate Matters More Than You Think

Bicarbonate isn’t just a number on a lab report. It’s your body’s main buffer against acid. When levels drop, your body starts breaking down muscle to make ammonia, which neutralizes acid. That’s why people with untreated metabolic acidosis lose muscle mass fast-even if they’re eating enough protein. Bones also start dissolving to release calcium carbonate, which fights acid. Over time, this leads to osteoporosis and fractures. Studies show that keeping bicarbonate above 22 mEq/L cuts the risk of kidney function dropping by half. The chronic kidney disease community now treats this like a core part of care, not an afterthought.

The Go-To Treatment: Sodium Bicarbonate

Sodium bicarbonate tablets (650 mg each, giving about 7.6 mEq of bicarbonate) are the most common fix. A major 3-year trial with 740 CKD patients found that taking 0.5-1.0 mEq/kg/day slowed the decline of kidney function by nearly 6 mL/min/1.73m² compared to placebo. That’s the difference between needing dialysis in 8 years versus 5. But there’s a catch: each 500 mg tablet has 610 mg of sodium. For someone with high blood pressure or heart failure, that’s dangerous. Many patients see their blood pressure jump from 130/80 to 160/95 within weeks. That’s why doctors don’t just prescribe it blindly-they check fluid status, heart health, and sodium intake first.

Alternatives to Sodium Bicarbonate

If you can’t tolerate sodium bicarbonate, there are other options. Calcium citrate is one. It gives alkali without the sodium, but each pill adds calcium. Long-term use raises the risk of kidney stones by 27%. Potassium citrate sounds good-no sodium, good for bones-but it’s risky in CKD. About 18% of patients on potassium supplements develop dangerous high potassium levels. In fact, 22% of stage 4 CKD patients on potassium citrate hit potassium above 5.0 mEq/L. That’s a heart rhythm threat. Sodium citrate (Shohl’s solution) is another option, but it’s often too salty or tastes awful. Many patients mix it with orange juice, adding sugar they shouldn’t have.

A patient balancing sodium pills against healthy foods on a cosmic scale, with vibrant colors.

Diet Can Help-If You Stick With It

Food plays a bigger role than most realize. Meat, cheese, and processed grains are acid factories. A 100g serving of beef adds +9.5 mEq of acid. A slice of cheddar? +8.0 mEq. Fruits and vegetables? They’re acid fighters. Apples, broccoli, spinach-they each subtract 2-3 mEq per 100g. Studies show that shifting 50% of your plate to plant-based foods can slash your daily acid load by 40-60 mEq. One patient in Cleveland Clinic’s CKD clinic raised their bicarbonate by 3.5 mEq/L in six months just by swapping burgers for lentils and chicken for tofu. But it’s hard. Most people don’t know which foods are acidic. A renal dietitian usually needs to walk you through it. And even then, only 35% of patients hit the target of a neutral or negative PRAL score.

The New Kid on the Block: Veverimer and Beyond

Veverimer was supposed to be the game-changer. It’s a pill that traps acid in your gut without being absorbed-so no sodium, no potassium, no calcium. Phase 2 trials showed a 4.3 mEq/L bicarbonate boost in 12 weeks. But the phase 3 trial in 2021 missed its goal. The difference from placebo was just 2.07 mEq/L-not enough to get FDA approval. The company is trying again in 2024 with new data. Meanwhile, a new citrate-free alkali supplement called TRC001 is showing promise in early trials: a 4.1 mEq/L rise in bicarbonate with half the stomach upset of traditional options. It’s not out yet, but it’s one to watch.

Who Gets Treated-and Who Doesn’t

Here’s the uncomfortable truth: only 43% of CKD patients with low bicarbonate get any treatment. And it’s worse for Black patients (38%) and those in rural areas (35%). Many doctors still don’t test bicarbonate regularly. Some think it’s not urgent. But KDIGO guidelines say clearly: if your bicarbonate is below 22 mEq/L, start alkali therapy. The evidence is strong. Yet, in practice, it’s still missed. Partly because there’s no branded drug approved just for this. Everything used is off-label. Partly because patients can’t handle the pill burden. On average, people take 4.2 pills a day. That’s a lot when you’re already taking meds for blood pressure, diabetes, and cholesterol.

A kitchen transformation where food turns into glowing plants, and a bicarbonate molecule rides a blood wave.

How to Monitor Progress

Don’t just start treatment and forget it. Check bicarbonate levels every month when you begin. Once you’re stable, every 3-6 months is fine. Target? 23-29 mEq/L, per KDIGO. But experts are shifting. The 2024 draft guidelines suggest 22-29 mEq/L, recognizing that even 22 mEq/L protects your kidneys. For someone with heart failure, aim for 24-26 mEq/L. For an older, frail patient, 22-24 mEq/L may be safer. It’s not one-size-fits-all. Your doctor should adjust based on your age, heart health, and nutrition. And always track your potassium and calcium levels if you’re on citrate or calcium-based therapies.

What Patients Are Saying

On forums like Reddit and the American Kidney Fund’s community, patients are honest. One person wrote: “I switched from sodium bicarbonate to calcium citrate, but now I have to swallow six pills a day and still get leg cramps.” Another said: “The baking soda powder tastes like chalk. I mix it in orange juice, but I know I shouldn’t be drinking that much sugar.” Adherence is the biggest hurdle. Taste, pill count, side effects like bloating and nausea-all these stop people from sticking with treatment. But those who do? They report feeling less tired, less muscle loss, and fewer hospital visits. One woman said her eGFR held steady for three years after switching to diet + low-dose bicarbonate. She’s still not on dialysis.

The Big Picture: Why This Matters

Correcting metabolic acidosis isn’t about feeling better today. It’s about keeping your kidneys working longer. The National Institute of Diabetes and Digestive and Kidney Diseases estimates that if every eligible CKD patient got proper treatment, we could prevent 28,000 cases of kidney failure each year in the U.S. That’s $1.4 billion in saved healthcare costs. But we won’t get there until doctors start testing bicarbonate routinely, patients get better support for diet changes, and we have safer, easier-to-take medications. Right now, we’re treating a treatable condition like it’s inevitable. It’s not.

What You Can Do Right Now

Ask your doctor for a serum bicarbonate test if you have CKD stage 3 or higher.
If your level is below 22 mEq/L, ask about starting alkali therapy-and discuss your options: sodium bicarbonate, calcium citrate, or diet first.
Get a referral to a renal dietitian. Learn which foods add acid and which fight it.
Track your blood pressure and swelling if you’re on sodium bicarbonate.
Don’t take potassium citrate unless your potassium is low and your doctor specifically recommends it.
Keep your pill count manageable. If you’re taking more than 4 tablets a day, ask if there’s a simpler way.

20 Comments

Elizabeth Crutchfield
December 3, 2025 AT 22:53

i just started taking bicarb and honestly? it feels like a whole new person. no more constant tiredness. still getting used to the chalky taste though.
Chad Handy
December 4, 2025 AT 09:56

The notion that metabolic acidosis is somehow a benign byproduct of CKD is dangerously outdated. The data is unequivocal: chronic low-grade acidosis accelerates nephron loss through direct tubulointerstitial fibrosis and upregulation of the renin-angiotensin system. Sodium bicarbonate is not a luxury-it is a disease-modifying intervention. The fact that it remains underutilized speaks volumes about systemic medical inertia and the absence of pharmaceutical incentives for off-label use.
Chase Brittingham
December 4, 2025 AT 21:40

I get why people hate the pills. I tried sodium bicarb for two weeks and my BP shot up like a rocket. Switched to calcium citrate and now I'm down to three pills a day. Still gotta watch my calcium levels but at least I'm not feeling like a balloon. Also, the diet shift helped more than I thought-lentils over burgers? Game changer.
Bill Wolfe
December 5, 2025 AT 23:00

People who think 'just eat more vegetables' is a cure-all clearly haven't read the actual studies. You can't out-eat a GFR of 28. And yes, I'm calling out the wellness influencers who treat CKD like a yoga problem. This isn't about 'detoxing'-it's biochemistry. And if you're taking potassium citrate without monitoring levels, you're playing Russian roulette with your heart. 🤡
Benjamin Sedler
December 7, 2025 AT 07:00

Sodium bicarb is basically just baking soda in a pill. And yeah, it's cheap as hell. But the real joke? Doctors act like it's some miracle drug when it's been around since the 1800s. Meanwhile, veverimer gets a whole phase 3 trial and still flops. We're treating a 200-year-old fix like it's cutting-edge tech. Meanwhile, the real issue? Nobody wants to talk about how hard it is to eat like a monk when you're broke and tired.
zac grant
December 8, 2025 AT 07:33

PRAL score is the unsung hero here. If you're not tracking it, you're flying blind. I use a free app that auto-calculates acid load based on food logs. My score went from +42 to -11 in 4 months. Bicarb stayed at 25. No meds. Just food. It's not magic-it's math. And yeah, it's tedious. But so is dialysis.
michael booth
December 8, 2025 AT 12:10

I appreciate the comprehensive overview. The clinical data presented is robust and aligns with current KDIGO recommendations. It is imperative that healthcare providers prioritize routine serum bicarbonate monitoring in all stage 3 and above CKD patients. Early intervention yields significant long-term benefits in both renal preservation and quality of life.
Carolyn Ford
December 10, 2025 AT 11:20

I can't believe people still take sodium bicarb without checking their sodium intake first. You think your BP is fine? You're lying to yourself. And don't even get me started on potassium citrate-people are popping it like candy. You think you're helping your bones? You're just setting yourself up for a trip to the ER with a heart arrhythmia. And yes, I've seen it. Twice.
Heidi Thomas
December 11, 2025 AT 20:19

You all are overcomplicating this. Bicarb is the answer. Period. If you can't swallow pills, get the powder. Mix it with water. Drink it. Stop whining about taste. I've been on it for 5 years. My GFR didn't drop. My muscles stayed. End of story. The rest is just noise from people who don't want to take responsibility.
Dematteo Lasonya
December 13, 2025 AT 00:03

I’ve been on calcium citrate for 8 months now. My bicarb went from 19 to 24. My bone density scan improved. But I still get leg cramps at night. I wonder if it’s the calcium or just the CKD. Anyone else have this? I’m not sure if I should add magnesium or just live with it.
Gillian Watson
December 13, 2025 AT 07:58

In the UK, we don't get sodium bicarb as a standard prescription unless you're in a trial. Most GPs don't even know to test it. I had to push for the bloodwork myself. Took 6 months. Felt like I was begging for basic care. It's frustrating when the science is clear but the system is broken.
Martyn Stuart
December 13, 2025 AT 08:59

The real barrier isn't the meds-it's the cost and the complexity. I'm on 7 pills a day already. Adding more is a logistical nightmare. And diet? I work two jobs. I don't have time to weigh broccoli. We need simpler solutions. Like a once-daily pill that doesn't taste like chalk or make your BP explode.
Shofner Lehto
December 14, 2025 AT 23:41

I tried veverimer in the trial. It worked. My bicarb went up. No side effects. But then they stopped the trial. No explanation. Just... gone. I miss it. Now I'm back to the chalk. I wish they'd just approve it already. People are suffering because of bureaucracy.
Yasmine Hajar
December 15, 2025 AT 02:46

I used to think this was just about kidneys. Then I lost 12 lbs of muscle in 6 months. I couldn't lift my grandkids. That's when I realized: this isn't just a lab number. It's your body eating itself. I switched to diet + low-dose bicarb. Now I can carry groceries again. And I'm not on dialysis. This saved my life.
Karl Barrett
December 16, 2025 AT 04:15

The metabolic acidosis-CKD link is a perfect example of how physiology drives pathology. The body's compensatory mechanisms-muscle proteolysis, bone resorption-are evolutionary adaptations gone rogue in the context of chronic renal insufficiency. We're not just treating a lab value; we're interrupting a self-perpetuating cascade of catabolism. The fact that this is still not frontline care is a moral failure.
Jake Deeds
December 17, 2025 AT 02:16

I know people say diet helps, but let's be real-most of us are not gourmet chefs with time to meal prep. I eat what's cheap. What's fast. What my kid likes. And no, I'm not going to swap my grilled cheese for tofu. This isn't a lifestyle blog. It's a survival guide. And if the system expects me to eat like a hippie, it's not listening.
val kendra
December 17, 2025 AT 09:04

I started eating more veggies and honestly? I feel better. Not because of the science-because I stopped feeling guilty every time I ate. My doc says my bicarb is up. I didn't even take a pill. Just swapped out the processed stuff. Still take my sodium bicarb though. Two a day. No complaints.
Isabelle Bujold
December 18, 2025 AT 03:07

I've been tracking my PRAL for over a year now. It's not perfect, but it's the only thing that's kept me off dialysis. I used to think I was eating 'healthy'-grilled chicken, salad, etc. Turns out, chicken is acidogenic. And cheese? A nightmare. I switched to lentils, tofu, cauliflower rice, and a ton of leafy greens. My acid load dropped 58%. Bicarb went from 18 to 26. No meds added. Just food. And yes, it's boring. But I'm still here.
George Graham
December 18, 2025 AT 20:25

I used to think this was just about kidneys. Then I saw my dad lose his independence because no one checked his bicarb. He was tired, weak, fell three times. They blamed age. We found out his bicarb was 17. He started bicarb and within 3 months, he was walking again. He's 78. Not a miracle. Just science. Don't wait until it's too late.
John Filby
December 20, 2025 AT 12:47

I mix my bicarb powder with unsweetened cranberry juice. Tastes way better than orange juice. No sugar crash. And I feel like I'm doing something right. Still takes 4 pills a day but at least I don't gag every time. 🙌