Bicarbonate Test

Your body generates acid constantly, from every meal you digest, every muscle you contract, and every breath you take. Bicarbonate (HCO3-) is the molecule your blood uses to neutralize that acid and keep your pH stable. When bicarbonate drops too low or climbs too high, it signals that something in your kidneys, lungs, or metabolism is out of balance, often years before you feel any symptoms.

What makes this number especially useful is that it sits at the intersection of kidney health, heart risk, and metabolic function. Large population studies have consistently shown that people whose bicarbonate falls outside a surprisingly narrow sweet spot face higher risks of death from cardiovascular disease, faster kidney decline, and even a greater chance of developing diabetes.

What Bicarbonate Tells You

Every cell in your body produces carbon dioxide as a byproduct of burning fuel for energy. That CO2 dissolves in your blood and combines with water to form carbonic acid, which immediately splits into bicarbonate and a hydrogen ion (the particle that makes things acidic). This reaction is the core of your body's buffering system: bicarbonate soaks up excess acid to keep your blood pH locked between 7.35 and 7.45.

Your kidneys are the master regulators. They reclaim nearly 100% of the bicarbonate filtered through them each day and can manufacture new bicarbonate when your body faces an acid load. When kidney function slips, bicarbonate regeneration falls behind, and acid begins to accumulate. That is why bicarbonate often drops before other kidney markers look obviously abnormal.

The Mortality Sweet Spot

One of the clearest findings from the research is that bicarbonate has a U-shaped relationship with death risk: both low and high levels are associated with worse outcomes. The safest zone appears to be 22 to 26 mEq/L.

A study of over 31,000 U.S. adults followed for a median of 6.7 years found that people with bicarbonate below 22 mEq/L had a 54% higher risk of dying from any cause compared to those in the 22 to 26 range. On the high side, each 1 mEq/L increase above 26 raised cardiovascular death risk by 8%. These associations held after adjusting for age, kidney function, medications, and other health conditions.

In well-functioning older adults aged 70 to 79, the pattern persisted. Those with bicarbonate below 23 mEq/L had a 24% higher risk of dying over a decade of follow-up. Metabolic alkalosis (when blood is too alkaline) carried a 35% increased mortality risk as well.

Heart Failure and Cardiovascular Risk

Bicarbonate is not a test most people associate with heart health, but the cardiovascular signal is surprisingly strong. In a community-based study of over 6,200 adults without cardiovascular disease at baseline (the MESA cohort), each 1 mEq/L increase in bicarbonate was associated with a 13% higher risk of developing heart failure over 8.5 years of follow-up, among people not taking diuretics. Those with bicarbonate at or above 25 mEq/L also had measurably greater heart muscle mass and stiffer arteries.

Among people with existing kidney disease, the relationship becomes more complex. In the CRIC study, each 1 mEq/L increase in bicarbonate above 24 mEq/L raised heart failure risk by 14%. People whose bicarbonate stayed persistently above 26 had a 66% higher rate of heart failure and 36% higher mortality. This creates a tension with kidney-focused guidelines that encourage raising bicarbonate to protect kidney function, because overdoing it may harm the heart.

Kidney Function

Low bicarbonate is both a consequence and a driver of kidney disease. As your kidneys lose filtering capacity (measured by eGFR, or estimated glomerular filtration rate), they produce less bicarbonate. But the resulting acid buildup then accelerates further kidney damage, creating a vicious cycle. In the CRIC study, each 1 mEq/L increase in bicarbonate was associated with a 3% lower risk of kidney endpoints. For those with eGFR above 45, the protective effect was even larger: a 9% reduction per 1 mEq/L increase.

Even in people with preserved kidney function, low bicarbonate predicts trouble. In the MESA cohort, among participants with eGFR above 60 at baseline, each standard-deviation decrease in bicarbonate was linked to 12% higher odds of rapid kidney function decline. This suggests bicarbonate may detect early kidney stress that eGFR and standard urine tests miss.

Diabetes Risk

Bicarbonate may also serve as an early warning for metabolic dysfunction. In the Nurses' Health Study, women in the highest bicarbonate quartile had 25% lower odds of developing type 2 diabetes over 10 years. A separate study of over 5,300 adults in Beijing with normal fasting glucose found that those in the lowest bicarbonate quartile were about four times more likely to progress to impaired fasting glucose or diabetes.

Among people who already have type 2 diabetes, low bicarbonate carries an especially heavy toll. In a study of over 8,000 adults with diabetes, those with lower bicarbonate had a 40% higher risk of all-cause death, 48% higher cardiovascular death risk, and 84% higher cancer death risk compared to those with normal levels. Reduced kidney function explained roughly 12 to 17% of the link between low bicarbonate and death, suggesting most of the risk comes from other pathways.

Reference Ranges

Labs report bicarbonate as part of a basic or comprehensive metabolic panel, usually labeled "total CO2" or "CO2 content." This measurement includes dissolved carbon dioxide alongside bicarbonate, but bicarbonate makes up about 96% of the total, so the numbers are nearly interchangeable. Men tend to run slightly higher than women (average 26.6 vs. 25.0 mEq/L in one large study of healthy adults aged 18 to 40).

These tiers are drawn from large published studies. Your lab may use slightly different assays and cutpoints. The most meaningful approach is to compare your results within the same lab over time rather than treating any single threshold as absolute.

When Results Can Be Misleading

Bicarbonate has a within-person variability of about 3.2 to 3.5%, which means two consecutive readings need to differ by at least 2.6 mEq/L before you can be confident the change is real rather than normal biological fluctuation. Athletes tend to show even more variability (around 4 to 5%).

Sample handling matters more for this test than for most blood markers. Bicarbonate is stable for about four hours in a sealed, unspun tube and another two hours after the tube is opened and spun. Once a tube is opened to air, CO2 escapes and the reading can drift within an hour. If your result seems unexpectedly high, a sample that sat open too long could be the culprit.

A high-protein meal the night before your draw can temporarily lower bicarbonate by increasing your body's acid load. Intense exercise does the same thing by flooding your blood with lactic acid. For the most reliable baseline reading, aim for a draw taken in the morning after a typical evening meal and at least 24 hours after any hard workout.

Perhaps the most important interpretive trap: a low bicarbonate reading does not automatically mean metabolic acidosis. It can also result from chronic hyperventilation (respiratory alkalosis), which causes bicarbonate to drop as a normal compensatory response. Without knowing your blood pH or CO2 levels, a standalone bicarbonate value can be ambiguous. If your reading is unexpectedly low, an arterial or venous blood gas can resolve the question.

Tracking Your Trend

A single bicarbonate reading is a snapshot, not a verdict. Because individual set points vary and day-to-day fluctuations are real, watching your trend over time tells you far more than any one number. If your bicarbonate has been drifting downward across several readings, that trajectory matters even if every individual result technically falls within the "normal" range.

Get a baseline reading as part of a comprehensive metabolic panel. If you are making dietary changes (such as shifting toward a more plant-based diet to reduce acid load), retest in 3 to 6 months to see whether the shift is reflected in your numbers. After that, annual monitoring is sufficient for most people. If you have kidney disease, diabetes, hypertension, or you are taking medications that affect bicarbonate (diuretics, topiramate, or acetazolamide), more frequent monitoring, every 3 to 6 months, is appropriate.

Always compare results drawn from the same lab using the same assay. Switching labs can introduce enough measurement variation to make a real trend hard to distinguish from noise.