End stage of chronic kidney disease and metabolic acidosis

Czech version

Authors: J. Klaboch ¹; S. Opatrná ¹; K. Matoušovic ²; O. Schück ²
Authors‘ workplace: I. interní klinika Lékařské fakulty UK a FN Plzeň, přednosta prof. MUDr. Martin Matějovič, Ph. D. ¹; Interní klinika 2. lékařské fakulty UK a FN Motol Praha, přednosta prof. MUDr. Milan Kvapil, CSc., MBA ²
Published in: Vnitř Lék 2012; 58(7 a 8): 42-47
Category: 80th Birthday MUDr. Miroslav Mydlík, DrSc.

Overview

Renal function disorder is inevitably associated with metabolic acidosis. An adult produces approximately 1 mmol of acids/kg of body weight every day (3 mmol/kg in children), derived from metabolization of proteins from food. Development of metabolic acidosis in patients with kidney disease is based on accumulation of acids and insufficient production of bicarbonates; alkaline loss represents a marginal issue here limited to patients with type II renal tubular acidosis only. The prevalence of this disorder increases with declining glomerular filtration (GFR) from 2% in patients with GFR 1.0–1.5 ml/s/1.73 m² to 39% in patients with GFR < 0.3 ml/s/1.73 m² or, alternatively, to 19% in patients with GFR 0.25–0.3 ml/s/1.73 m². Notwithstanding the primary cause of the renal disease, declining GFR is associated with compensatory increase in ammoniac production in residual nephrons. This is an adaptive mechanism aimed at maintaining sufficient elimination of acids despite reduced volume of functional tissue. However, an increased ammoniac production simultaneously becomes a stimulus for activation of the complement via an alternative route and is thus one of the factors contributing, through this induced inflammation, to progression of tubular interstitial fibrosis that subsequently leads to further GFR reduction. Metabolic acidosis has a number of severe adverse effects on the organism, e.g. deterioration of kidney bone disease through stimulation of bone resorption and inhibition of bone formation, inhibition of vitamin D formation, increased muscle catabolism, reduced albumin production, glucose metabolism disorder, increased insulin resistance, reduced production of thyroid hormones, increased accumulation of β₂-microglobulin etc. Non-interventional studies suggest that alkali supplementation may slow down progression of chronic nephropathies. However, this approach, safe and inexpensive, has not been widely implemented in clinical practice yet. With respect to dialyzed patients, abnormal levels of bicarbonates are associated with increased mortality. Both metabolic acidosis and alkalosis, rather regularly seen in a considerable number of patients, have a negative effect on patient survival. Alkali substitution from a dialysis solution is the main pillar of metabolic acidosis management in patients on hemo- as well as peritoneal dialysis. Available technologies allow individualization of the treatment and this should be observed.

Key words:
metabolic acidosis – chronic kidney disease – hemodialysis – peritoneal dialysis – sodium bicarbonate – ammoniac

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