A basic solution for a complex problem: does treatment of metabolic acidosis slow CKD progression?

PURPOSE OF THIS REVIEW: Metabolic acidosis is frequently encountered in patients with chronic kidney disease (CKD), with increasing prevalence as kidney function worsens. Treating electrolyte disturbances is the sine qua non of Nephrologists, and alkali therapy to normalize serum bicarbonate levels and slow progression of kidney disease has been embedded in clinical practice guidelines for decades on the basis of animal models and controversial clinical trials. This review will critically appraise the literature base for this recommendation and determine whether the available evidence supports this common practice, which is a timely endeavor considering the impending demotion of metabolic acidosis treatment from recommendation to practice point in forthcoming KDIGO guidelines. RECENT FINDINGS: Earlier, open-label, studies supporting the utility of sodium bicarbonate therapy to slow progression of chronic kidney disease have been challenged by more recent, blinded, studies failing to show benefit on CKD progression. This was further demonstrated in the absence of concomitant sodium administration with the hydrochloric acid binder veverimer, which failed to demonstrate benefit on renal death, end stage kidney disease or 40% reduction in estimated glomerular filtration rate in a large multicenter trial. SUMMARY: The current body of literature does not support the routine treatment of metabolic acidosis in patients with CKD and the authors agree with the forthcoming KDIGO guidelines to de-emphasize this common practice.

Use of Multimodal Mechanical Support in Refractory Cardiogenic Shock From Bupropion Overdose.

Massive bupropion overdose has a known association with cardiogenic shock. We describe a clinical case of a 48-year-old female who was brought to the hospital by emergency medical services after ingesting numerous psychiatric medications. Her hospital course was complicated by worsening cardiogenic shock and ventricular tachycardia storm. Transthoracic echocardiography showed left ventricular (LV) hypokinesis with an ejection fraction of 9%. Then the patient underwent placement of a percutaneous Impella CP device (Abiomed, Danvers, MA). The Molecular Adsorbent Recirculating System was started for protein-bound bupropion clearance. After 24 hours, the patient returned to an organized sinus rhythm. A repeat echocardiogram done on the next day demonstrated improved LV function, and the patient had profound clinical improvement. The case illustrates how the use of extracorporeal membrane oxygenation in combination with Impella device and Molecular Adsorbent Recirculating System was able to support the patient's recovery.