Open Access Peer-Reviewed
Review Article

Metabolic acidosis in hemodialysis patients: a review

Acidose metabólica em pacientes em hemodiálise: uma revisão

Luiza Raksa Rezende; Pablo Brandão de Souza; Giselly Rosa Modesto Pereira; Jocemir Ronaldo Lugon

DOI: 10.5935/0101-2800.20170053


Metabolic acidosis is highly prevalent in hemodialysis patients. The disorder is associated with increased mortality and its deleterious effects are already present in the predialysis phase of chronic kidney disease. Metabolic acidosis has been linked to progression of chronic kidney disease, changes in protein and glucose metabolism, bone and muscle disorders and cardiovascular disease. At present, the control of metabolic acidosis in hemodialysis is mainly focused on the supply of bicarbonate during dialysis session, but further studies are needed to set the optimum target serum bicarbonate and the best concentration of the bicarbonate dialysate. The present study reviews pathophysiological and epidemiological aspects of metabolic acidosis in hemodialysis patients and also addresses its adverse effects and treatment.

acidosis; renal dialysis; bicarbonates.


A acidose metabólica é altamente prevalente em pacientes em hemodiálise. A doença está associada com mortalidade aumentada e os seus efeitos deletérios já estão presentes na fase pré-diálise da doença renal crônica. A acidose metabólica tem sido associada a progressão da doença renal crônica, alterações no metabolismo das proteínas e da glicose, doenças ósseas e musculares e enfermidades cardiovasculares. Atualmente, o controle da acidose metabólica em hemodiálise está voltado principalmente para o suprimento de bicarbonato durante a sessão de diálise, porém, mais estudos são necessários para definir o bicarbonato sérico alvo ideal e a melhor concentração de bicarbonato do banho. O artigo revisa os aspectos fisiopatológicos e epidemiológicos da acidose metabólica em pacientes em hemodiálise e também aborda seus efeitos adversos e tratamento.

acidose; diálise renal; bicarbonatos.


Citation: Rezende LR, Souza PB, Pereira GRM, Lugon JR. Metabolic acidosis in hemodialysis patients: a review. Braz. J. Nephrol. (J. Bras. Nefrol.) 39(3):305. doi:10.5935/0101-2800.20170053
Received: October 5 2016; Accepted: October 26 2016


End-stage renal disease (ESRD), which can be treated by either dialysis or transplantation, is a worldwide public health problem. Its incidence has increased in recent years, causing substantial economic burden to health care systems in the world.1,2 Of note, the mortality of dialysis patients remains elevated compared to general population with approximately half of the patients dying from cardiovascular disease.3

In Brazil, for example, according to the Brazilian Survey of Chronic Dialysis of 2014, the estimated total number of dialysis patients was 100,397. National estimates of the rates of prevalence and incidence of dialysis were 499 and 170 patients per million people, respectively. The annual rate of crude mortality was 17.9%. The absolute number of dialysis patients has increased 3% annually over the past three years.4

The presence of metabolic acidosis and its association with mortality in patients on dialysis has been the subject of several publications5-8 as summarized in Table 1. The real extent of this problem in Brazil is unknown because, in 1996, the national regulatory agency for the dialysis procedure has published an ordinance in which the mandatory measurement of bicarbonate in patients on renal replacement therapy (RRT) was withdrawn.9 The most recent Brazilian government guidelines recommend measurement of bicarbonate every six months (stage 4) or quarterly (stage 5), but only for patients undergoing conservative treatment,10 keeping measurement of this parameter in patients on RRT not mandatory.

Table 1. Selected studies evaluating the impact of metabolic acidosis on mortality in dialysis patients
  Study design Effects on mortality (Yes/No) Main results
Vashistha et al.5 Observational, retrospective, multicentric, n = 121,351 Yes Increase 15-35% in the risk of mortality for patients with bicarbonate < 22mEq/L.
(Database: DaVita)
Bommer et al.7 Observational, prospective, multicentric, n = 7,140 Yes Up to 48% increase in mortality risk for patients with pre-dialysis serum bicarbonate in a midweek session < 18mEq/L or = 27mEq/L.
(Database: DOPPS I)
Yamamoto et al.7 Observational, retrospective, multicentric, n = 15,132 No 36% increase in mortality risk for patients with predialysis pH > 7.40. No association was found between the levels of serum bicarbonate before or after dialysis with mortality.
(Database: Japanese Renal Data Registry)
Tentori et al.8 Observational, prospective, multicentric, n = 17,031 Yes Average 30% increase in mortality risk for patients with serum pre-dialysis bicarbonate = 17mEq/L.
(Database: DOPPS II)

Pathophysiology of metabolic acidosis

Metabolic acidosis can be defined as a pathological condition characterized by an absolute or relative increase in body concentration of hydrogen ions with a reduction in serum bicarbonate. The adult human body produces 1 mEq/kg body weight of endogenous free acids daily (in children the value is 2-3 mEq/kg of body weight).11 The acid balance in the body depends crucially on the quality and quantity of acids (mainly derived from proteins) and alkalis (sourced from fruits and vegetables) consumed in the diet and also on the amount of eliminated acids.12 The excretion of the acid produced by the metabolism is mainly accomplished by two pathways: the lungs, responsible for eliminating volatile acids; and the kidneys, for the non-volatile acids.

Produced endogenous acids are neutralized by the body buffers, including bicarbonate, which is reabsorbed by the glomeruli, assisting in maintaining the acid-base balance. The kidney''s ability to excrete acid and reabsorb bicarbonate is impaired when glomerular filtration rates (GFR) is below 40-50 ml/min, a point in which the installation of systemic metabolic acidosis generally initiates.13-15

Metabolic acidosis can be triggered by three major mechanisms: an increase in the generation of acid, bicarbonate loss, and decreased renal acid excretion. In ESRD patients, the major mechanism involved is the decrease in the renal excretion of hydrogen ions.16

In hemodialysis, the factors that can conceivably contribute to the worsening of metabolic acidosis include: low gain of bicarbonate in dialysis (caused by inadequate level of bicarbonate in the dialysate, inadequate dialysis schedule or absenteeism), high protein intake or gastrointestinal loss of bicarbonate.17,18

Disorders related to metabolic acidosis

The deleterious effects of metabolic acidosis are already present in the predialysis phase of chronic kidney disease. Although beyond the scope of the present review, it is noteworthy that a number of studies have posed metabolic acidosis as a nephrotoxic factor implicated in the progression of chronic kidney disease.19-22 The mechanism is thought to involve increased interstitial generation of ammonia (with activation of the complement pathway), augmented local production of endothelin, and activation of the RAAS. These players would promote renal interstitial fibrosis and acceleration of the nephron loss. Perhaps more important are the reports that the presence of metabolic acidosis is already associated with higher mortality even in the predialysis stage of CKD.23 The adverse effects of chronic metabolic acidosis are summarized in Figure 1.

Bone disorders

The changes that occur in bone mineral composition in the presence of metabolic acidosis suggest that it actively acts as a proton buffer. Consistent with this view, there is reduction of sodium and potassium bone (indicating exchange of protons), bone carbonate reduction (suggesting consumption of this buffer), and increased serum calcium.24

Also, increased calciuria is found without a parallel increase in intestinal calcium absorption suggesting that the bone is the source of the excreted calcium. In vitro studies indicate that during acute metabolic acidosis the initial bone calcium efflux is caused by physicochemical dissolution, whereas after 24 to 48 hours, it is predominantly mediated by cells. There is an increased concentration of prostaglandins, which stimulates the activity of osteoclasts and inhibits osteoblastos.25 Acidosis can also contribute to the mineral and bone disease of chronic kidney disease.26

In children, chronic metabolic acidosis can cause growth retardation. This phenomenon is not completely understood but may involve perturbation of the growth hormone/IGF-1 axis, whose serum levels are diminished, resulting in reduction of the protein anabolismo.27,28

Effects on protein catabolism

Metabolic acidosis is also associated with increased protein catabolism and a consequent decrease in muscle mass, which can be associated with increased morbidity and mortality in hemodialysis patients.29-31 In this regard, increased protein catabolism seems to play a more important role than decreased protein synthesis.32 The main mechanism underlying muscle degradation in metabolic acidosis involves the ubiquitin-proteasome pathway. Physiologically, this system is the major pathway degrading protein in skeletal muscle. In the presence of acidosis there is increased expression of mRNA ubiquitin, elevation in the number of proteasome subunits, and over activation of the system leading to increased protein degradation.33-35

Another factor that appears to contribute to sarcopenia is the enhanced endogenous production of glucocorticoids in patients with chronic metabolic acidosis.36 Glucocorticoids bind to phosphatidylinositol 3-kinase, leading to suppression of phosphorylation of Akt protein (essential for the intracellular signaling protein synthesis).37 With the decrease in Akt phosphorylated proteins, there is a reduction in protein synthesis and consequent muscle loss.

Still within this context, insulin has an anabolic action by increasing glucose intake by muscle cells and inhibiting proteolysis. Recent studies suggest that the presence of metabolic acidosis can inhibit the anabolic effects of insulin which could contribute to the reduction of muscle mass in patients with chronic kidney disease. This insulin resistance is independent of the body fat content and can be a risk factor for developing type 2 diabetes mellitus.38-40

Hemodynamic effects

Metabolic acidosis directly affects heart function. The precise mechanism by which acidosis perturbs the inotropic state of the heart remains unknown. Reductions in pH to values below 7.2 inhibit the Na+/K+ ATPase transporter and cause a reduction in the cardiomyocytes action potential, which result in a decrease of muscle contractile force and heart failure.41

Another mechanism triggered by acidosis that is also implicated in heart failure involves the calcium: hydrogen ions compete with these ions by binding to troponin in myocardial cells; in the presence of high concentrations of hydrogen a smaller percentage of calcium binds to troponin, disturbing the interaction between actin and myosin and causing reduction of cardiac contractile.42

Other hemodynamic event directly associated with acidosis is the vasodilation due to increased serum levels of nitric oxide.43 Nitric oxide induced vasodilation is exacerbated by the direct influence of the low pH in peripheral vascular resistance and in the response of the vessels to cathecolamines.42

Systemic inflammation and atherosclerosis

Chronic metabolic acidosis is associated with the onset of systemic inflammation and its deleterious consequences for the human body: anorexia, malnutrition, accelerated atherogenesis, and increased incidence of cardiovascular disease.3,44,45 Macrophages in acidic environment begin to produce greater quantities of tumor necrosis factor alpha and interleukins, which triggers an inflammatory reaction.46 Furthermore, the renal failure by itself is associated with increased circulating cytokines, also contributing to the development of the inflammatory process.47

Chronic metabolic acidosis may be the trigger for most of the mechanisms underlying the malnutrition/inflammation/atherosclerosis syndrome, which is known to affect hemodialysis patients.44 Patients with chronic metabolic acidosis show increased endothelial permeability and a more rapid development of atherosclerosis. Autopsies48 and clinical studies49 have shown that atherosclerotic plaques in coronary arteries are higher in hemodialysis patients when compared to the general population. In an experimental study, it was found that acidotic rabbits had increased endothelial permeability43. This increase in endothelial permeability leads to retention of oxidized LDL-cholesterol in the intima of arteries and can contribute to progression of atherosclerosis.50


The mainstay in the treatment of chronic metabolic acidosis in end-stage renal failure patients is the supply of exogenous bicarbonate. This is usually provided by the dialysate containing bicarbonate during the dialysis sessions and, if necessary, orally. The target serum bicarbonate recommended by the KDOQI51 is at least 22 mEq/L immediately before a hemodialysis session, but the recommendation does not specify if the number refers to the first dialysis session of the week or a midweek one. A recent review on the Subject,52 based on a large observational study,6 commentates that the best survival was found with bicarbonate before the mid-week session between 18 and 21 mEq / L.

Hemodialysis is currently the main way to supply bicarbonate and control of acidosis. Sixty-five percent of the dialysate bicarbonate crosses the membrane in one pass through the filter. This high value is responsible for the rapid increase in serum bicarbonate in the first two hours of dialysis; for the remainder of the hemodialysis session the serum bicarbonate only increases slightly or remains stable. At the end of the treatment alkalinity is about 4 to 7 mEq/L smaller than the bicarbonate dialysate. The probable cause for this stabilization at the end of HD is the reduction in bicarbonate concentration gradient and perhaps increased production of organic acids due to the rapid increase of álcalis.53,54

Theoretically, the prescription of the bicarbonate dialysate should be individualized according to the serum levels of bicarbonate of each patient. This strategy is indeed adopted in some centers especially in developed countries,8 but it does require a more personalized attention by the care team and is difficult to apply as a routine procedure. In fact, the reality for the majority of dialysis centers is a standard prescription that is considered acceptable for the average population of each clinic. However, taking the differences in diet and catabolic state of each patient in consideration, it is unlikely that a single pattern is able to adequately treat all patients.

At the present, the limitations of the dialysis treatment in the control of metabolic acidosis results in a high frequency of this disorder in ESRD patients. Possible strategies to increase the performance of the dialysis treatment regarding control of the metabolic acidosis include increasing the concentration of bicarbonate in the dialysate,54,55 and more frequent or longer dialysis sessions.56 A modeling process in which the dialysate bicarbonate concentration varies along the session has been tested, however, no clear benefits over traditional hemodialysis was found.54,57

There is a wide variation in the dialysate bicarbonate concentration between countries with values ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States.8 The increase in the dialysate bicarbonate concentration has been much discussed as the main way to control acidosis in hemodialysis patients as an inexpensive and easy method.

However, the adoption of this practice still demands more conclusive studies since the resultant metabolic alkalosis carries the potential to be as harmful as metabolic acidosis. A recent study showed an association between an 8% increase in overall mortality of dialysis patients for each increase of 4 mEq / L in the dialysate bicarbonate concentration.8 The best concentration of dialysis bath bicarbonate is yet to be established.

Several mechanisms may be involved with the disputable increase in mortality related to metabolic alkalosis per or post-dialysis, such as: reduction in the ionized fraction of calcium and consequent reduction in myocardial contraction,58 hypokalemia,59 changes in ventricular repolarization,60,61 hemodynamic instability62,63 and cardiopulmonary arrest (Figure 2).64-66

Oral supplementation of sodium bicarbonate in the interdialytic period may also be considered in order to individualize the bicarbonate replacement. However, one should take into consideration that many of these patients regularly use a substantial amount of oral medications that can hinder adherence to prescription. Also, one should always be alert to the possible risk of sodium overload with the use of this supplement.67,68

The proper management of metabolic acidosis in patients on hemodialysis should also include the control of causative factors, such as inadequate hemodialysis and excessive intake of protein. The ancillary tools in this regard include: dialysis prescription optimization; surveillance for the prescription to be fulfilled; and encouragement to reduce absenteeism.

Although excessive intake of proteins can be harmful by aggravating acidosis, maintain adequate nutrition and preventing protein catabolism is of great importance in ESRD patients. Therefore, a protein intake around 1.2g/kg/day is required and excess acid production may be offset by increased supply of bicarbonate as opposed to dietary restriction.67-69


Chronic metabolic acidosis is closely related to chronic kidney disease and ESRD. Its presence in patients undergoing hemodialysis has been associated with mortality.

Much has been discussed about the best strategy to approach this acid-base disturbance since the metabolic alkalosis during and after the dialysis, caused by an increase in supply of bicarbonate by hemodialysis, may be potentially harmful to the patient.

A cutoff value for predialysis blood bicarbonate that would provide the lowest mortality is not yet clearly established, but it seems to seat between 18 and 22 mEq/L. Similarly, the most effective value of the dialysate bicarbonate concentration in this regard is also uncertain.

The obstacles to establishing a standard for the dialysate bicarbonate concentration probably stems from differences in the diet and biophysical profiles of patients, which are the main determinants of their alkali needs. Oral supplementation would allow easier customization of the individual requirements. However, this practice comes up against the difficulty of joining the prescription and the risk of salt and water retention.


International comparisons. In: U.S. Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda: U.S. Renal Data System; 2012. p. 341-52.
Cost of ESRD. In: U.S. Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda: U.S. Renal Data System; 2012. p. 329-40.
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32:S112-9. PMID: 9820470 Link PubMed
Sesso RC, Lopes AA, Thomé FS, Lugon JR, Martins CT. Brazilian Chronic Dialysis Census 2014. Braz. J. Nephrol. (J. Bras. Nefrol.) 2016;38:54-61.
Vashistha T, Kalantar-Zadeh K, Molnar MZ, Torlén K, Mehrotra R. Dialysis modality and correction of uremic metabolic acidosis: relationship with all-cause and cause-specific mortality. Clin J Am Soc Nephrol 2013;8:254-64.
Bommer J, Locatelli F, Satayathum S, Keen ML, Goodkin DA, Saito A, et al. Association of predialysis serum bicarbonate levels with risk of mortality and hospitalization in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2004;44:661-71. PMID: 15384017 Link PubMed
Yamamoto T, Shoji S, Yamakawa T, Wada A, Suzuki K, Iseki K, et al. Predialysis and Postdialysis pH and Bicarbonate and Risk of All-Cause and Cardiovascular Mortality in Long-term Hemodialysis Patients. Am J Kidney Dis 2015;66:469-78. PMID: 26015276 Link PubMed
Tentori F, Karaboyas A, Robinson BM, Morgenstern H, Zhang J, Sen A, et al. Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2013;62:738-46.
Brasil. Ministério da Saúde. Portaria nº 2.042, de 11 de outubro de 1996. Estabelece o Regulamento Técnico para o funcionamento dos Serviços de Terapia Renal Substitutiva e as normas para cadastramento desses estabelecimentos junto ao Sistema Único de Saúde. Ministério da Saúde. Brasília: Ministério da Saúde; 1996.
Brasil. Ministério da Saúde. Diretrizes Clínicas Para o Cuidado ao Paciente com Doença Renal Crônica - DRC no Sistema Único de Saúde. Brasília: Ministério da Saúde; 2014.
Scialla JJ, Anderson CA. Dietary acid load: a novel nutritional target in chronic kidney disease? Adv Chronic Kidney Dis 2013;20:141-9.
Kraut JA, Madias NE. Metabolic Acidosis of CKD: An Update. Am J Kidney Dis 2016;67:307-17.
Riella MC, Riella CV, Pachaly MA, Riella LV. Metabolismo da água. In: Riella MC, org. Princípios de nefrologia e distúrbios hidroeletrolíticos. 5ª ed. Rio de Janeiro, Brasil: Guanabara Koogan; 2010. p. 105-38.
Widmer B, Gerhardt RE, Harrington JT, Cohen JJ. Serum electrolyte and acid base composition. The influence of graded degrees of chronic renal failure. Arch Intern Med 1979;139:1099-102. PMID: 485740 Link PubMed
Warnock DG. Uremic acidosis. Kidney Int 1988;34:278-87. PMID: 3054224 Link PubMed
Halperin ML, Goldstein MB. Fluid, Electrolyte, and Acid-Base Physiology - A Problem-Based Approach. 3rd ed. Philadelphia: Saunders; 1999.
Soudan K, Ricanati ES, Leon JB, Sehgal AR. Determinants of metabolic acidosis among hemodialysis patients. Hemodial Int 2006;10:209-14.
Saikumar JH, Kovesdy CP. Bicarbonate Therapy in End-Stage Renal Disease: Current Practice Trends and Implications. Semin Dial 2015;28:370-6.
Kovesdy CP. Metabolic acidosis and kidney disease: does bicarbonate therapy slow the progression of CKD? Nephrol Dial Transplant 2012;27:3056-62.
Ng HY, Chen HC, Tsai YC, Yang YK, Lee CT. Activation of intrarenal renin-angiotensin system during metabolic acidosis. Am J Nephrol 2011;34:55-63.
Wesson DE. Regulation of kidney acid excretion by endothelins. Kidney Int 2006;70:2066-73. PMID: 17021604 DOI: Link PubMed
Phisitkul S, Khanna A, Simoni J, Broglio K, Sheather S, Rajab MH, et al. Amelioration of metabolic acidosis in patients with low GFR reduced kidney endothelin production and kidney injury, and better preserved GFR. Kidney Int 2010;77:617-23. PMID: 20072112 Link PubMed
Kraut JA, Madias NE. Consequences and therapy of the metabolic acidosis of chronic kidney disease. Pediatr Nephrol 2011;26:19-28.
Bushinsky DA. Acidosis and bone. Miner Electrolyte Metab 1994;20:40-52.
Krieger NS, Frick KK, Bushinsky DA. Mechanism of acid-induced bone resorption. Curr Opin Nephrol Hypertens 2004;13:423-36.
Lefebvre A, de Vernejoul MC, Gueris J, Goldfarb B, Graulet AM, Morieux C. Optimal correction of acidosis changes progression of dialysis osteodystrophy. Kidney Int 1989;36:11121-8.
Brüngger M, Hulter HN, Krapf R. Effect of chronic metabolic acidosis on the growth hormone/IGF-1 endocrine axis: new cause of growth hormone insensitivity in humans. Kidney Int 1997;51:216-21. PMID: 8995736 Link PubMed
Kuemmerle N, Krieg RJ Jr , Latta K, Challa A, Hanna JD, Chan JC. Growth hormone and insulin-like growth factor in non-uremic acidosis and uremic acidosis. Kidney Int Suppl 1997;58:S102-5. PMID: 9067956 Link PubMed
Griffiths RD. Muscle mass, survival, and the elderly ICU patient. Nutrition 1996;12:456-8.
Bonanni A, Mannucci I, Verzola D, Sofia A, Saffioti S, Gianetta E, et al. Protein-energy wasting and mortality in chronic kidney disease. Int J Environ Res Public Health 2011;8:1631-54.
Kovesdy CP, Kalantar-Zadeh K. Why is protein-energy wasting associated with mortality in chronic kidney disease? Semin Nephrol 2009;29:3-14.
May RC, Kelly RA, Mitch WE. Mechanisms for defects in muscle protein metabolism in rats with chronic uremia. Influence of metabolic acidosis. J Clin Invest 1987;79:1099-103. PMID: 3549778 DOI: Link PubMed
Lecker SH, Goldberg AL, Mitch WE. Protein degradation by the ubiquitin-proteasome pathway in normal and disease states. J Am Soc Nephrol 2006;17:1807-19.
Mitch WE, Goldberg AL Mechanisms of muscle wasting. The role of the ubiquitin-proteasome pathway. N Engl J Med 1996;335:1897-905.
Bailey JL, Wang X, England BK, Price SR, Ding X, Mitch WE. The acidosis of chronic renal failure activates muscle proteolysis in rats by augmenting transcription of genes encoding proteins of the ATP-dependent ubiquitin-proteasome pathway. J Clin Invest 1996;97:1447-53.
Bailey JL, Zheng B, Hu Z, Price SR, Mitch WE. Chronic kidney disease causes defects in signaling through the insulin receptor substrate/phosphatidylinositol 3-kinase/Akt pathway: implications for muscle atrophy. J Am Soc Nephrol 2006;17:1388-94.
Hu Z, Wang H, Lee IH, Du J, Mitch WE. Endogenous glucocorticoids and impaired insulin signaling are both required to stimulate muscle wasting under pathophysiological conditions in mice. J Clin Invest 2009;119:3059-69. PMID: 19759515 Link PubMed
Garibotto G, Sofia A, Russo R, Paoletti E, Bonanni A, Parodi EL, et al. Insulin sensitivity of muscle protein metabolism is altered in patients with chronic kidney disease and metabolic acidosis. Kidney Int 2015;88:1419-26.
Williams RS, Kozan P, Samocha-Bonet D. The role of dietary acid load and mild metabolic acidosis in insulin resistance in humans. Biochimie 2015;124:171-7.
Williams RS, Heilbronn LK, Chen DL, Coster AC, Greenfield JR, Samocha-Bonet D. Dietary acid load, metabolic acidosis and insulin resistance - Lessons from cross-sectional and overfeeding studies in humans. Clin Nutr 2016;35:1084-90.
Brown RH Jr, Cohen I, Noble D. The Interactions of protons, calcium and potassium ions on cardiac Purkinje fibres. J Physiol 1978;282:345-52. PMID: 31464 Link PubMed
Mitchell JH, Wildenthal K, Johnson RL Jr. The effects of acid-base disturbances on cardiovascular and pulmonary function. Kidney Int 1972;1:375-89.
Khazaei M, Nematbakhsh M. Effect of experimentally induced metabolic acidosis on aortic endothelial permeability and serum nitric oxide concentration in normal and high-cholesterol fed rabbits. Arch Med Sci 2012;8:719-23.
Kalantar-Zadeh K, Mehrotra R, Fouque D, Kopple JD. Metabolic acidosis and malnutrition-inflammation complex syndrome in chronic renal failure. Semin Dial 2004;17:455-65. DOI:
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296-305. PMID: 15385656 Link PubMed
Bellocq A, Suberville S, Philippe C, Bertrand F, Perez J, Fouqueray B, et al. Low environmental pH is responsible for the induction of nitric-oxide synthase in macrophages. Evidence for involvement of nuclear factor-kappaB activation. J Biol Chem 1998;273:5086-92.
Stenvinkel P, Barany P, Heimbürger O, Pecoits-Filho R, Lindholm B. Mortality, malnutrition, and atherosclerosis in ESRD: what is the role of interleukin-6? Kidney Int Suppl 2002;80:103-8. PMID: 11982823 Link PubMed
Collins AJ. Cardiovascular mortality in end-stage renal disease. Am J Med Sci 2003;325:163-7. PMID: 12695721 Link PubMed
Bax L, van der Graaf Y, Rabelink AJ, Algra A, Beutler JJ, Mali WP; SMART Study Group. Influence of atherosclerosis on age-related changes in renal size and function. Eur J Clin Invest 2003;33:34-40.
Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med 1999;340:115-26. PMID: 9887164 Link PubMed
Guideline 15. Metabolic Acidosis. In: KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease [cited 2017 Aug 22]. Available from:
Kraut JA, Nagami GT. The use and interpretation of serum bicarbonate concentration in dialysis patients. Semin Dial 2014;27:577-9.
Panupong Lisawat P, Gennari FJ. Approach to the hemodialysis patient with an abnormal serum bicarbonate concentration. Am J Kidney Dis 2014;64:151-5.
Tovbin D, Sherman RA. Correcting Acidosis during Hemodialysis: Current Limitations and a Potential Solution. Semin Dial 2016;29:35-8.
Williams AJ, Dittmer ID, McArley A, Clarke J. High bicarbonate dialysate in haemodialys patients: effects on acidosis and nutritional status. Nephrol Dial Transplant 1997;12:2633-7. DOI:
National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update. Am J Kidney Dis 2015;66:884-930. PMID: 26498416 Link PubMed
Harris DC, Yuill E, Chesher DW. Correcting acidosis in hemodialysis: effect on phosphate clearance and calcification risk. Am Soc Nephrol 1995;6:1607-12.
van Kuijk WH, Mulder AW, Peels CH, Harff GA, Leunissen KM. Influence of changes in ionized calcium on cardiovascular reactivity during hemodialysis. Clin Nephrol 1997;47:190-6. PMID: 9105767 Link PubMed
Fissell R, Hakim RM. Improving outcomes by changing hemodialysis practice patterns. Curr Opin Nephrol Hypertens 2013;22:675-80.
Severi S, Grandi E, Pes C, Badiali F, Grandi F, Santoro A. Calcium and potassium changes during haemodialysis alter ventricular repolarization duration: in vivo and in silico analysis. Nephrol Dial Transplant 2008;23:1378-86.
Di Iorio B, Torraca S, Piscopo C, Sirico ML, Di Micco L, Pota A, et al. Dialysate bath and QTc interval in patients on chronic maintenance hemodialysis: pilot study of single dialysis effects. J Nephrol 2012;25:653-60.
Gabutti L, Ferrari N, Giudici G, Mombelli G, Marone C. Unexpected haemodynamic instability associated with standard bicarbonate haemodialysis. Nephrol Dial Transplant 2003;18:2369-76.
Gabutti L, Bianchi G, Soldini D, Marone C, Burnier M. Haemodynamic consequences of changing bicarbonate and calcium concentrations in haemodialysis fluids. Nephrol Dial Transplant 2009;24:973-81.
Jadoul M, Thumma J, Fuller DS, Tentori F, Li Y, Morgenstern H, et al. Modifiable practices associated with sudden death among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study. Clin J Am Soc Nephrol 2012;7:765-74.
Pun PH, Lehrich RW, Honeycutt EF, Herzog CA, Middleton JP. Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics. Kidney Int 2011;79:218-27. PMID: 20811332 Link PubMed
Green D, Roberts PR, New DI, Kalra PA. Sudden cardiac death in hemodialysis patients: an in-depth review. Am J Kidney Dis 2011;57:921-9. PMID: 21496983 DOI: Link PubMed
Saikumar JH, Kovesdy CP. Bicarbonate Therapy in End-Stage Renal Disease: Current Practice Trends and Implications. Semin Dial 2015;28:370-6.
Basile C, Rossi L, Lomonte C. The choice of dialysate bicarbonate: do different concentrations make a difference? Kidney Int 2016;89:1008-15.
Guideline 15. Dietary Protein Intake (DPI) in Maintenance Hemodialysis (MHD). In: KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure [cited 2017 Aug 22]. Available from:

© 2018 All rights reserved