Whilst observational evidence suggests that metabolic acidosis in chronic kidney disease (CKD) is a driver of CKD progression, there remains significant debate regarding the quantity and quality of published evidence to support treatment. The Kidney Disease: Improving Global Outcomes (KDIGO) guidance on metabolic acidosis in CKD highlighted this controversy by publishing practice points, not recommendations, based primarily on placebo-controlled randomized controlled trials. These practice points suggest considering treatment to prevent metabolic acidosis with a proposed cut-off for serum bicarbonate