For more information, see Sterns RH: 10 Nephrology: I Renal Function and Disorders of Water and Sodium Balance. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, September 2003
Disorders of Acid-Base and Potassium Balance
A 22-year-old woman presents to the emergency department with nausea, vomiting, and abdominalpain of 4 days' duration. Her fluid balance profile is as follows: Na
, 145; K
, 5.0; Cl-, 105; HCO
-, 15;BUN, 37; Cr, 1.6; glucose, 780; UA, 4+ ketones.
What is the best initial treatment of this patient's acid-base disorder?
C.Normal saline, sodium bicarbonate, and insulin
D.Half-normal saline and insulin
E.Normal saline and insulin
Key Concept/Objective: To understand the diagnosis and treatment of diabetic ketoacidosis
Metabolic acidosis can be classified into two types: that associated with an elevation inthe anion gap, and that in which the anion gap is normal. A calculation of the aniongap in this patient reveals a gap of 25. Among the causes of acidosis associated with anelevated anion gap are alcoholic ketoacidosis, lactic acidosis, starvation, ingestion of alcohols, ingestion of salicylates, and diabetic ketoacidosis. In patients with diabeticketoacidosis (such as this patient), optimal initial treatment includes fluid replacementwith normal saline to promote ketonuria and insulin to facilitate glucose transport.Bicarbonate therapy is not usually indicated unless the acidosis is severe or severehyperkalemia is present.
(Answer: E—Normal saline and insulin)
A 42-year-old woman presents with nausea, vomiting, and left flank pain with radiation to the groin;these symptoms have persisted for 3 days. A helical CT scan reveals a stone in the left ureter. On the basisof urinalysis and serum chemistries, a diagnosis of type 1 renal tubular acidosis (RTA) is made.
Which of the following is NOT consistent with type 1 RTA?
A.Normal-anion-gap metabolic acidosis
B.Urine pH < 5.3
D.Urinary calcium phosphate crystals
Key Concept/Objective: To understand the diagnosis of type 1 RTA
Renal tubular acidosis is one of the causes of normal-anion-gap metabolic acidosis.Other causes are administration of HCl and losses of bicarbonate from the gastroin-testinal tract. Type 1 RTA may be congenital, or it may occur in association with vari-ous immune disorders, such as Sjögren syndrome. The underlying defect involves theinability of the intercalated cells of the collecting tubule to pump out hydrogen ions.As a result, the urine pH is always greater that 5.3. Hypokalemia occurs secondary toenhanced Na
exchange in the distal tubule, because hydrogen ions are not secretedin response to sodium reabsorption. A major complication of type 1 RTA is nephrocal-cinosis. Nephrocalcinosis is caused by calcium phosphate crystals, which occur second-ary to an increase in the resorption of proximal tubular citrate through metabolic aci-dosis. The decrease in urinary citrate facilitates the precipitation of calcium phosphatecrystals in the collecting tubule.
(Answer: B—Urine pH < 5.3)
10 NEPHROLOGY 3