Why Metabolic Acidosis in CKD Patients Is Being Dangerously Overlooked

Chronic Kidney Disease (CKD) remains a growing global health concern, yet a critical complication often goes unnoticed. Metabolic acidosis, a condition linked to worsening kidney function, is frequently overlooked due to low testing rates. In Japan, recent findings reveal that fewer than one in ten eligible CKD patients received annual serum bicarbonate checks between 2014 and 2021.

Metabolic acidosis develops in CKD when failing kidneys struggle to remove excess hydrogen ions and restore bicarbonate balance. This imbalance can accelerate disease progression and increase complications. Despite its seriousness, the condition is rarely monitored or treated.

Data from Japan shows that even when bicarbonate levels were measured, nearly half of patients met criteria for clinically significant acidosis. The problem worsened with advancing CKD stages. Yet only 8.6% of those with levels below 22 mEq/L—the threshold for diagnosis—were formally identified as having acidosis. Treatment rates were even lower, with just 7.5% receiving alkali therapy, usually sodium bicarbonate. Experts recommend routine bicarbonate testing as part of CKD care, given its low cost and ease of integration into standard lab panels. However, systemic barriers persist, with no other country publishing recent studies on testing frequency. Addressing this gap would require updated guidelines, better clinician education, and automated inclusion of bicarbonate assays in kidney function tests.

The underdiagnosis of metabolic acidosis in CKD highlights a missed opportunity for improving patient care. Wider adoption of bicarbonate testing could lead to earlier interventions and reduced complications. Without systemic changes, however, the condition will likely remain overlooked despite its prevalence and impact.