Low Serum Bicarbonate and CKD Progression in Children

Clin J Am Soc Nephrol. 2020 Jun 8;15(6):755-765. doi: 10.2215/CJN.07060619. Epub 2020 May 28.


Background and objectives: Studies of adults have demonstrated an association between metabolic acidosis, as measured by low serum bicarbonate levels, and CKD progression. We evaluated this relationship in children using data from the Chronic Kidney Disease in Children study.

Design, setting, participants, & measurements: The relationship between serum bicarbonate and a composite end point, defined as 50% decline in eGFR or KRT, was described using parametric and semiparametric survival methods. Analyses were stratified by underlying nonglomerular and glomerular diagnoses, and adjusted for demographic characteristics, eGFR, proteinuria, anemia, phosphate, hypertension, and alkali therapy.

Results: Six hundred and three participants with nonglomerular disease contributed 2673 person-years of follow-up, and 255 with a glomerular diagnosis contributed 808 person-years of follow-up. At baseline, 39% (237 of 603) of participants with nonglomerular disease had a bicarbonate level of ≤22 meq/L and 36% (85 of 237) of those participants reported alkali therapy treatment. In participants with glomerular disease, 31% (79 of 255) had a bicarbonate of ≤22 meq/L, 18% (14 of 79) of those participants reported alkali therapy treatment. In adjusted longitudinal analyses, compared with participants with a bicarbonate level >22 meq/L, hazard ratios associated with a bicarbonate level of <18 meq/L and 19-22 meq/L were 1.28 [95% confidence interval (95% CI), 0.84 to 1.94] and 0.91 (95% CI, 0.65 to 1.26), respectively, in children with nonglomerular disease. In children with glomerular disease, adjusted hazard ratios associated with bicarbonate level ≤18 meq/L and bicarbonate 19-22 meq/L were 2.16 (95% CI, 1.05 to 4.44) and 1.74 (95% CI, 1.07 to 2.85), respectively. Resolution of low bicarbonate was associated with a lower risk of CKD progression compared with persistently low bicarbonate (≤22 meq/L).

Conclusions: In children with glomerular disease, low bicarbonate was linked to a higher risk of CKD progression. Resolution of low bicarbonate was associated with a lower risk of CKD progression. Fewer than one half of all children with low bicarbonate reported treatment with alkali therapy. Long-term studies of alkali therapy's effect in patients with pediatric CKD are needed.

Keywords: acidosis; alkalis; anemia; bicarbonates; chronic; chronic kidney disease; chronic metabolic acidosis; demography; glomerular filtration rate; hypertension; longitudinal studies; pediatrics; phosphates; proteinuria; renal insufficiency; renal progression; renal replacement therapy.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acidosis / blood*
  • Acidosis / drug therapy
  • Acidosis / etiology
  • Adolescent
  • Bicarbonates / blood*
  • Bicarbonates / therapeutic use
  • Buffers
  • Child
  • Child, Preschool
  • Disease Progression
  • Female
  • Follow-Up Studies
  • Humans
  • Kaplan-Meier Estimate
  • Kidney Glomerulus
  • Male
  • Proportional Hazards Models
  • Prospective Studies
  • Renal Insufficiency, Chronic / blood*
  • Renal Insufficiency, Chronic / etiology
  • Renal Insufficiency, Chronic / physiopathology
  • Renal Insufficiency, Chronic / therapy
  • Renal Replacement Therapy


  • Bicarbonates
  • Buffers