Treatment of metabolic acidosis in chronic kidney disease with fruits and vegetables but not sodium bicarbonate yields fewer adverse cardiovascular events after five-years follow up

Background: Chronic kidney disease (CKD) patients have increased risk for myocardial infarction (MI) and cerebrovascular accident (CVA) and metabolic acidosis further increases this risk. Nevertheless, whether treatment of metabolic acidosis in CKD reduces risk for these CVD outcomes is not known. Current guidelines recommend Na+-based alkali like NaHCO3 for CKDrelated metabolic acidosis but recent studies, however, support that metabolic acidosis can also be treated with base-producing fruits and vegetables (F+V) which themselves might reduce CVD risk. We tested the hypothesis that F+V treatment of metabolic acidosis reduces adverse CVD events in CKD better than NaHCO3. Methods: One hundred eight non-diabetic CKD patients with stage 3 estimated GFR (30-59 ml/min/1.73m2 ) with metabolic acidosis but with plasma [HCO3] above which current guidelines recommend treatment (> 22 meq/L) were randomized to receive F+V (n=36) in amounts to reduce dietary acid 50%, oral NaHCO3 (HCO3, n=36) 0.3 meq/Kg bw/day to approximate base equivalence of F+V, or to Usual Care (UC, n=36). All had a systolic blood pressure (SBP) goal < 130 mm Hg and were assessed annually, including serum LDL, for five years. The number of adverse CVD events (MI + CVA) was compared among the three groups at year five of follow up. Results: Baseline parameters were similar among groups except SBP was lower (p=0.04) in UC (159 ± 11 mm Hg) than HCO3 (165 ± 10 mm Hg) and F+V (163 ± 12 mm Hg). Adverse CVD events at year five were significantly different among the three groups (p=0.03) with there being no (0) such events in F+V but 5 in UC and 2 in HCO3. Possible contributors to the lower number of adverse events in F+V vs. HCO3 include a greater patient percentage (%, 95% confidence interval or CI) of F+V (89%, CI=73-97) than HCO3 (17%, CI=7-34) that achieved their SBP goal of < 130 mm Hg; and a five-year net LDL decrease greater in F+V (-45.5 mg/dl, CI= -50.9 to -40.1) than in HCO3 -21.5 mg/dl, CI= -26.9 to -16.1). Conclusion: Treatment of CKD-related metabolic acidosis with F+V better reduced adverse CVD events more than NaHCO3, possibly due to better SBP control and greater LDL reduction. These data support further exploration of F+V as a potentially better metabolic acidosis treatment option to reducing CVD outcomes in CKD.