Optimising acid-base balance in patients with advanced chronic kidney disease: a quality improvement initiative

Advanced chronic kidney disease (CKD) is commonly associated with disturbances in acid-base balance. Studies have shown that correcting metabolic acidosis in CKD offers several clinical benefits, including slower disease progression and reduced mortality. Acidosis can be addressed with oral sodium bicarbonate, an easy-to-administer and relatively inexpensive treatment compared with novel drugs such as sodium-glucose co-transporter-2 -(SGLT-2) inhibitors. Although sodium bicarbonate is frequently prescribed in CKD, less attention is paid as to whether serum bicarbonate levels are adequately optimised. This project aimed to increase the proportion of advanced CKD patients with serum bicarbonate levels within the normal range.Retrospective data collection was conducted at our tertiary renal centre to establish baseline bicarbonate levels and assess prescribing practices for sodium bicarbonate. Quality improvement (QI) methodology was then applied to implement a series of interventions designed to increase awareness of acidosis and to promote the appropriate use of oral sodium bicarbonate.Results from baseline data collection showed that 94% of patients had a serum bicarbonate level checked within the previous 6 months. However, only 46% of patients had levels within the optimal range. Although initial improvement was noted following our first intervention, this was not sustained through subsequent QI cycles, and the proportion of patients with optimal bicarbonate levels remained largely unchanged by the end of the project.Optimising serum bicarbonate is an important component of the management of advanced CKD. While this project led to increased awareness and short-term gains, further work is required to achieve lasting improvements and embed change into routine practice.