Management of metabolic acidosis covers the entire spectrum from oral bicarbonate therapy and dietary modifications in chronic kidney disease to delivery of high doses of bicarbonate-based dialysate during maintenance haemodialysis (MHD). Due to the gradual depletion of the body's buffers and rapid repletion during MHD, many potential problems arise as a result of our current treatment paradigms. Several studies have given rise to conflicting data about the adverse effects of our current practice patterns in MHD. In this review, we will describe the pathophysiology and consequences of metabolic acidosis and its therapy in CKD and ESRD, and discuss current evidence supporting a more individualized approach for bicarbonate therapy in MHD.
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