Shohl’s solution

Solutions that contain sodium citrate/citric acid (Shohl s solution and Bicitra) provide 1 mEq/L (1 mmol/L) each of sodium and bicarbonate. Polycitra is a sodium/potassium citrate solution that provides 2 mEq/L (2 mmol/L) of bicarbonate, but contains 1 mEq/L (1 mmol/L) each of sodium and potassium, which can promote hyperkalemia in patients with severe CKD. The citrate portion of these preparations is metabolized in the liver to bicarbonate, while the citric acid portion is metabolized to C02 and water, increasing tolerability compared to sodium bicarbonate. Sodium retention is also decreased with these preparations. However, these products are liquid preparations, which may not be palatable to some patients. Citrate can also promote aluminum toxicity by augmenting aluminum absorption in the GI tract. 

In patients with Stage 3 or higher CKD, the use of aUcalinizing salts, such as sodium bicarbonate or citrate/citric acid preparations, is useful to replenish depleted body bicarbonate stores. Sodium bicarbonate tablets are manufactured in 325- and 650-mg strengths (a 650-mg tablet contains 7.7 mEq sodium and 7.7 mEq bicarbonate). Shohl s solution and Bicitra contain 1 mEq/mL of sodium and the equivalent of 1 mEq/mL of bicarbonate as sodium citrate/citric acid. Citrate is metabolized in the liver to bicarbonate, and citric acid is metabolized to CO2 and water. Polycitra, which contains potassium citrate, (1 mEq/mL of sodium, 1 mEq/mL of potassium, and 2 mEq/mL of bicarbonate) should not be used in patients with severe CKD since hyperkalemia may result. 

Shohl s solution Bicitra (Willen) 1 mEq Na/mL equivalent to Solution (500 mg Na citrate, Citrate preparations... 

Reduction of urine acidity can be accomplished by the administration of sodium bicarbonate or Shohl s solution (40 g citric acid and 98 g sodium citrate per liter). With the former, 2 to 6 g/day is given in equally divided doses at 6- to 8-hour intervals. A dose of 20 to 60 mL of ShohTs solution per day, given in three or four divided doses, provides an equivalent amount of alkali. If use of a sodium salt is contraindicated, potassium citrate may be used instead. 

Severe acidemia impairs cardiac contractility and predisposes to arrhythmias. Treatment with sodium bicarbonate or Shohl s solution (sodium citrate and citric acid) is in order if the blood pH falls below 7.2 (Nl). Dialysis should be started when uremia and acidosis are more advanced. 

Furthermore, certain factors may increase intestinal aluminum absorption. We have previously described severe hyperaluminemia resulting in an acute rapidly fatal encephalopathy in four uremic patients who had been taking aluminum hydroxide and Shohl s solution, an alkalinizing buffer of sodium citrate and citric acid. The encephalopathy resembled the earlier dialysis dementia of the 1970s, but was much more acute, culminating in death within 3 weeks (B4, B5). 

---