A CKD patient has metabolic acidosis with HCO3- 16 mEq/L. What is the first-line management?

• A. Begin bicarbonate therapy (oral sodium bicarbonate) to correct metabolic acidosis
• B. Immediately initiate dialysis
• C. Chronically restrict bicarbonate intake
• D. Administer potassium binders and reassess later

Answer: (A)

Metabolic acidosis in CKD is treated by replacing the deficient bicarbonate to restore a normal acid-base balance. With a bicarbonate level at 16 mEq/L, the first-line step is oral bicarbonate therapy (usually sodium bicarbonate) to raise the level toward about 22–24 mEq/L. Correcting the acidosis can help slow CKD progression and improve bone and nutritional health. Dialysis is not the initial move unless acidosis is severe or unresponsive to medical therapy, and restricting bicarbonate or using potassium binders alone does not address the underlying acid-base disturbance. Start bicarbonate therapy and monitor response with follow-up labs, adjusting the dose to reach the target bicarbonate level.