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After completing this case study, the reader should be able to:

  • Determine the clinical and laboratory manifestations of metabolic acidosis.

  • Differentiate the most probable cause(s) of metabolic acidosis.

  • Develop a patient-specific pharmacotherapeutic plan for treating chronic metabolic acidosis.

  • Provide medication education for patients with chronic metabolic acidosis.


Chief Complaint

“I just feel so weak all the time.”


Sue Rider is a 67-year-old woman with progressive CKD due to HTN, who was referred to the nephrology clinic for management of fatigue. Her fatigue started a couple years ago but has progressed to the point that it interferes with her gardening and evening walks. She reports occasional muscle cramps (one every 1–2 months) that last a few seconds to minutes and are not associated with exertion. She reports frequent nonadherence to her furosemide when she feels well.



CKD stage 4

Seasonal allergic rhinitis

Menopause at 53 years old


History of CAD in her mother’s family (mother had a heart attack at age 60). No known family history of CKD.


The patient is a retired schoolteacher who lives with her husband of 38 years and has three grown children. She denies alcohol use. There is no history of tobacco habituation or recreational drug use.


Amlodipine 5 mg PO daily

Aspirin 81 mg PO daily

Furosemide 40 mg PO daily, taken intermittently for lower extremity edema (reports that she has not taken any for the past few months)

Metoprolol succinate 25 mg PO daily




Fatigue worsening over the past two years. Denies weight changes or changes in appetite. Denies fever/chills. No palpitations, shortness of breath or chest pain. Denies abdominal pain, nausea/vomiting, and melena. Admits to weakness and reports occasional myalgia but is not experiencing currently.



Pleasant African-American woman in NAD


BP 155/85 mm Hg, P 78 bpm, RR 16, T 37.2°C; Wt 165 lb (75 kg), Ht 5′4″ (162.5 cm)


Normal color and texture. Intact, warm and dry.


No hemorrhages or exudates on funduscopic ...

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