At what serum bicarbonate level do you initiate alkali therapy for patients with chronic kidney disease?  

I find that there is a lot of variability between different laboratories in their serum CO2 levels. As such, I don't think this is a one-size-fits-all all situation. At my lab, which tends to have higher CO2 levels, I start bicarbonate therapy once the serum CO2 level is at or below 20 mEq/L.

I generally treat CKD patients with alkali before they have any decline in serum bicarbonate levels. There is ample lab evidence that the renal compensation for maintaining acid base balance with a reduced GFR involves an increase in ammoniagenesis by residual nephrons. This process is, experimental...

The new KDIGO guidelines is 19 instead of 22.