Would you start sodium citrate for patients with advanced chronic kidney disease and metabolic acidosis who fail to reach serum bicarbonate target despite high doses of sodium bicarbonate?

I don't think sodium citrate is any more effective than sodium bicarbonate in improving metabolic acidosis. Sodium bicarbonate is more likely to cause gastric distention and air. If that results in noncompliance, then it is worth switching. It is also important these patients are on diuretic as much...

Yes, I would certainly give it a try as long as not on any aluminum-containing medications.