,

. ,
/ . , /

-2-

pH
+. pH 7.40 ( 7.36-7.44),
+ 40 nmol/L ( 36-44 nmol/L).
+ (>44 nmol/L),
pH (<7.36), ,
+ (<36 nmol/L), pH (>7.44),
. +
( 16-160 nmol/L),

, .
, +
. pH

.
(buffers) ,
.
(HCO3-) . HCO3-
+: HCO3- + H+

H2CO3

CO2 +H2O

CO2 . HCO3-/H2CO3

pH
Henderson-Hasselbach:

To K . pK
HCO3-/H2CO3 6.1 37C. O 0.03
CO2 . pH
HCO3-/PCO2, PCO2 CO2.

-3-

: + = 24 X PCO2/HCO3-, +
nmol/L, PCO2 mmHg HCO3- mmol/L.
(H2C3) .
CO2 2. CO2 2,
H2CO3 (CO2 + H2O

H2CO3

H+ + HCO3-)

, 16.000-22.000 mmol CO2

. ,
.
50-100 mmol
(1 mmol/kg ) ( ) ,
.
,
,
+.
PCO2 pH.
HCO3-, ,
(+) pH. ,

.

(. ),
HCO3-
pH.
HCO3-
+ .
+ (intercalated) .
4
.
: (1) ,
(buffers)
pH (2) ,

-4-

pH. , .
: () ,
, ()
. ,
, ,
, ()

pH.

PCO2.
CO2 ( PCO2)
(H2CO3).
HCO3-.
,
PCO2.

PCO2. HCO 3-
HCO3-.
,
.
pH ,
pH
(7.36-7.44).
,
.
2 3
.
.

. ,
, HCO3-

-5-

, .
HCO3-
, , HCO 3-
.

.
: pH: 7.36-7.44, PCO2 (mmHg): 37-43 HCO3- (mmol/L): 22-26.

.
, pH
. ,
2 .
,
.
2. ,
,
,
pH PCO2 . , pH
0.03-0.04 pH ,
PCO2
7-8 mmHg. HCO3- 2 mmol/L
.
pH
PCO2 ( 2). , HCO3-
Henderson Hasselbach.

-6-

DuBose TD. Clinical approach to patients with acid-base disorders. Med Clin North Am
1983; 76: 799-813.
Emmett M, Narins RG. Clinical use of the anion gap. Medicine 1977; 56: 38-54.
Kassirer JP, Bleich HC. Rapid estimation of plasma carbon dioxide from pH and total
carbon dioxide content. N Engl J Med 1965; 272: 1067-1072.
Kraut JA, Madias NE. Approach to the diagnosis of acid-base disorders. In: Textbook of
Nephrology, eds. Massry SG, Glassock RJ, Williams & Wilkins, Baltimore 1989;
405-412.
Madias NE, Adrogue HJ, Cohen JJ, Schwartz WB. Effect of natural variations in PaCO 2
on plasma [HCO3-] in dogs: A redefinition of normal. Am J Physiol 1979; 236: F30F36.
Madias NE, Adrogue HJ, Horowitz GL, Cohen JJ, Schwartz WB. A redefinition of normal
acid-base equilibrium in man: CO2 tension as a key determinant of normal
plasma bicarbonate concentration. Kidney Int 1979; 16: 612-619.
Narins RG, Emmett M. Simple and mixed acid-base disorders: A practical approach.
Medicine 1980; 59: 161-187.
Rose BD. Acid-base physiology. In: Clinical physiology of acid-base and electrolyte
disorders, eds. Rose BD, McGraw-Hill Inc, New York 1994; 274-299.

-7-

) METAB

,
pH, HCO3-
PCO2 .
+
HCO3- (H+ + HCO3-

H2CO3

H2O+CO2),

+ HCO3-.

pH. : ()
( HCO3-) +, ()
( ) +
. + +,
. +
, ()
( )
PCO2. HCO3- 1 mmol/L
PCO2 1.2 mmHg. ,
, PCO2
HCO3-
HCO3-, () .
, 50-100 mmol +
, 4+ 2P04- (
). (
), 4+
.
T 1. ,

, ,
+ HCO3- .

-8-

1.

(,
,
, , NH4Cl, )

HCO3) (, , , -)
) (
)

() .
.
,
( 2).
Na+ - (HCO3- + Cl-) 9-14 mmol/L.
: ()
()
.

2.

= :
Na + = Cl- + HCO3- +
- = Na+ - (HCO3- + Cl-)
XA = Na+ - (HCO3- + Cl-)
+

-9-

, +
(-), + NaHCO3
+CO2+H2O,

NaA

().
, , , (..
) .

( 3). ,
( )
.
,
. ,
.
, D-
.
D- ( L- ).
.
(>4 mmol/L)

.
3.

(PO2<25-30 mmHg)
CO

D-
: , , ,

(+
)

-10-

( )
.

.
,
+ HCO3-,
.

, +
Cl-, Cl + NaHCO3

NaCl + CO2 + H2O,

, HCO 3-
Cl- ( ).
NaCl,
HCO3- (.. ), HCO3- (..
), V
NH4Cl.
NaCl 0.9%,
, HCO3- (dilutional acidosis).
, Na+
, Cl- .
, NH4Cl, .

HCO3-. , , ,
Na+ ( ), Cl-
, HCO3-.
HCO3-
.

-11-

,

. 80%
2 . ,
, Cl - - HCO3-
Cl- HCO3-. , Cl-
HCO3-, . ,
4+,
, .
4+ 3 +. ,
,
().

.
,
4+
HCO3-.

() IV.
+. (
) , Sjogren,
. ,
.
o +.
. , ,
, .
HCO 3-.
( ) ,

D . ,
.

-12-

, , ,
( Fanconi).

. V
+ +.
IV
.

4+ 24, ,
IV,
NH4+. E 4+
,
4+ . : =
Na+ + K+ - Cl- ( ).
( ) ()
.

pH . pH pH
,
3. pH
, ,
. pH
5.3
( ).
4 .

 4.

(>14 mmol/L)

(9-14 mmol/L)
4+ 24
4+ (>50 mmol/24)

()

HCO3 HCO3 NH4Cl

4+ (<50 mmol/24)

pH

<5.3
IV

>5.3

+
,

( ,
)

+

()

-14-

pH 7.2,

.
NaHCO3. HCO3-
,
HCO3- pH
. , pH
7.2-7.25 , , : (1)
pH (
), (2) pH
,
2, 2 , (3)
+ ,
, (4) NaHCO3
, .
HCO3-
: HCO3- (mmol) = 0.6 (kg) ( HCO3- HCO3-). ,
HCO3-, HCO3-
6/10 .

HCO3- 10 mmol/L . , ,
NaHCO3, HCO3- 10-12
mmol/L, .
. , HCO3- ,
.
HCO3- ,
HCO3-
. , ,
HCO3- : () (pH <7) ()

.

-15-

.
,
, HCO3-.
HCO3- ,
pH
.
HCO3-,
,
,
. : ()
, () , () , ()
C2 + HCO3-,
PCO2, , ()
6, () Ca++,
pH
, HCO3- Ca++.
Ca++ .
NaHCO3,
NaHCO3, pH
7.10, 7.2-7.25 .
+
( HCO3-),
HCO3- .

-16-

Adrogue HJ, Brensilver J, Cohen JJ, Madias NE. Influence of steady-state alterations in acidbase equilibrium on the fate of administered bicarbonate in the dog. J Clin Invest 1983;
71: 867-883.
Adrogue HJ, Brensilver J, Madias NE. Changes in the plasma anion gap during chronic
metabolic acid-base disturbances. Am J Physiol 1978; 235: F291-F297.
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acute metabolic acidosis in conscious dogs. J Clin Invest 1985; 75: 798-808.
Adrogue HJ, Madias NE. Changes in plasma potassium concentration during acute acid-base
disturbances. Am J Med 1981; 71: 456-467.
Adrogue HJ, Rashad MN, Gorin D, et al. Assessing acid-base status in circulatory failure:
differences between arterial and central venous blood. N Engl J Med 1989; 320: 13121316.
Alpern RJ. Trade-off in the adaptation to acidosis. Kideny Int 1995; 47: 1205-1215.
Battle DC, Arruda JAL, Kurtzman NA. Hyperkalemic distal renal tubular acidosis associated
with obstructive uropathy. N Engl J Med 1981; 304: 373-380.
Battle DC, Hizon M, Cohen E, et al. The use of the urinary anion gap in the diagnosis of
hyperchloremic metabolic acidosis. N Engl J Med 1988; 318: 594-595.
Battle DC, Sehy JT, Roseman MK, et al. Clinical and physiologic spectrum of acquired distal
renal tubular acidosis. Kidney Int 1981; 20: 389-396.
Battle DC. Segmental characterization of defects in collecting tubule acidification. Kidney Int
1986; 20: 546-554.
Brenner RJ, Spring DB, Sebastian A, et al. Incidence of radiographcally evident bone disease,
nephrocalcinosis, and nephrolithiasis in various types of renal tubular acidosis. N Engl J
Med 1982; 307: 217-221.
Chattha G, Arieff AI, Cummings C, Tierney LM. Lactic acidosis complicating the acquired
immunodeficiency syndrome. Ann Intern Med 1993; 118: 37-39.
Clark DD, Chang BS, Garella S, Cohen JJ, Madias NE. Secondary hypocapnia fails to protect
whole body intracellular pH chronic HCl acidosis in the dog. Kidney Int 1983; 23: 336341.
Cohen EP, Bastani B, Cohen MR, Kolner S, Hemken P, Gluck SL. Absence of H +-ATPase in
cortical collecting tubules of a patient with Sjogrens syndrome and distal tubular
acidosis. J Am Soc Nephrol 1992; 3: 264-271.
Cooper DJ, Walley KR, Wiggs BR, et al. Bicarbonate does not improve hemodynamics in
critically ill patients who have lactic acidosis. Ann Intern Med 1990; 112: 492-498.
Curthoys NP, Gstraunthaler G. Mechanism of increased renal gene expression during
metabolic acidosis. Am J Physiol Renal Physiol 2001; 281: F381-390.
Elisaf M, Merkouropoulos M, Tsianos E, Siamopoulos KC. Acid-base and electrolyte
abnormalities in alcoholic patients. Miner Electrolyte Metab 1994; 20: 274-281.
Elisaf M, Merkouropoulos M, Tsianos EV, Siamopoulos KC. Acid - base abnormalities in
chronic alcoholic patients. Hellenic Journal of Gastroenterology 1997; 10: 59-63.

-17-

Elisaf M, Siamopoulos KC. Acid - base and electrolyte abnormalities in patients with
congestive heart failure. Clin Exp Cardiol 1997; 2: 140 144.
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Elisaf M, Tsatsoulis AA, Katopodis K, Siamopoulos KC. Acid - base and electrolyte
disturbances in patients with diabetic ketoacidosis. Diab Res Clin Pract 1996; 34: 23-27.
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2002; 18: 289-308.
Halperin ML, Hammeke M, Josse RG, Jungas RL. Metabolic acidosis in the alcoholic: A
pathophysiologic approach. Metabolism 1983; 32: 308-315.
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key to the diagnosis of distal renal tubular acidosis. Nephron 1988; 50: 1-4.
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metabolic acidosis. J Lab Clin Med 1984; 104: 15-23.
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-18-

Vasuvattakul S, Warner LC, Halperin ML. Quantitative role of the intracellular bicarbonate
buffer system in response to an acute acid load. Am J Physiol 1992; 262: R305-R309.
M. N . E N 1997; 9(4): 416-433.
, . .
1990; 3: 27-31.
, . . 1990; 58: 138-143.
, .
. 1991; 1: 30-36.
, . . 1992; 6(4): 378381.
, . .
, . 1991; 3(4): 274-286.

-19)

,
pH,
HCO3- , PCO2.
5. ,
HCO3- (.. )
CO3-, + .
, ,
HCO3-, HCO3- (contraction alkalosis).
,

K +
+ . HCO3-
, HCO3- . ,
(maintenance) (
HCO3-), , HCO3-
. HCO3- ,
.
5.

+
:
:

+ :
HCO3-:

,
,
Bartter

-
,

HCO3-)
NaHCO3

(contraction
alkalosis)
Cl- HCO3( )

-20-

pH PCO2.
HCO3- 1 mmol/L PCO2 0.7 mmHg.

. ,
(,
.) .
Cl-
,
. , Cl- <15 mmol/L ,
, , ,
NaCl (
). , Cl - (>20 mmol/L)


( ).

.

.
(.. ),
.
(250-375 mg 2 )
.
, NaHCO3 ,
.

Cl. E NH4Cl ,

.

-21-

Adrogue HJ, Brensilver J, Madias NE. Changes in the plasma anion gap during chronic
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-22-

Madias NE, Levey AS. Metabolic alkalosis due to absorption of nonabsorbableantacids. Am J

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-23)

CO2 ,
PCO2 pH.
6

, ,

.
6.

:
(, , ), ,
- , 2

:
( Pickwickian)

:
,
,
, Guillain-Barre,

,
,

:
, , -

:





:

HCO3-.

, HCO3 .

-24-

PCO2 10 mmHg HCO3- 1 mmol/L,

HCO3- 3.5 mmol/L.

(, , , , , ),
pH ,
. , pH
7.10 ,
.
.
Na+ .

. , pH
.
(
)
. + Cl-,
, KCl. ,

.

-25-

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-26)

.
pH (
+), CO2 (PCO2). ,
HCO3- .

HCO3- ,
.
+ .
+ HCO3- HCO3-
. , PCO2 10 mmHg HCO3-
2 mmol/L.
+, 2
2-3 .
pH. ,
PCO2 10 mmHg HCO3- 4-5 mmol/L.
PCO2

CO2. ,
( 2<60 mmHg),
(
) ( 7).
7.

:
,

gram-



(.. , )

-27-

(,
, , ,
)
.
( 40% PCO2 20 mmHg). ,

2 2
.
. ,
Ca++ Ca++ .

. (
)
, ,
,
(, ).
i PCO 2
25-30 mmHg pH . ,
( pH )
, pH
HCO3- ,
.
O
. , ( )
.
. ,
, .
,
, . ,
, ( ),
.
(.. ),
.

-28-

.
,
.
,
PCO2 ,
. pH,
HCO3-
, PCO2 .

-29-

Cohen JJ, Madias NE, Wolf CJ, et al. Regulation of acid-base equilibrium in chronic
hypocapnia. J Clin Invest 1976; 57: 1483-1489.
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2975-2976.
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Madias NE, Bossert WH, Adrogue HJ. Ventilatory response to chronic metabolic acidosis and
alkalosis in the dog. J Apll Physiol 1984; 56: 1640-1646.
Madias NE. Regulation of acid-base equilibration in respiratory acidosis and alkalosis. :
4 , 1986: 42-45.
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84: 1997-2001.
M.
. E I 1999; 45-51.

-30-

2
)

2 : ,
. 2
:
(). 2 ,

, , 2

.
, 1
6.02 1023 .
kg H2O (mOsm/kg).
mmol/L, mg/dl mEq/L
mOsm/kg : n X mmol/L = mOsm/kg, n X mg/dl X 10/MB =
mOsm/kg, n X mEq/L/ = mOsm/kg, n
. n=1, (.. ), 1
mmol/L 1 mOsm/kg. ,
2 , 1 mmol/L 2 mOsm/kg.
Na +
( Cl- HCO3-), .
.
mmHg, (osmolality) mOsm/kg 2,
,
2.
,
(Na+, ).
, (, ), mg/dl mmol/L
18 6. Na+,
( mmol/L) . ,
(Posm) :

-31-

(mg/dl)
+

Posm (mOsm/kgH2O) = 2 x Na (mmol/L) +

(mg/dl)
+

(1)

18

( 275-290 mOsm/kg)

. 5-10
mOsm/kg,
. , : () Na +
, ()
, , , , ,
.
2
,
2
2.
(),
2 .
(.. Na +, ,
.) :
(mg/dl)
= 2 Na

(mmol/L) +

(2)
18

( : 270-285 mosmol/kg)

A,
, ,
Na +
H2O.

-32) O-

Na+
/. ,
, 2
.

().
,
.
.
2 ( ) 2 (
ADH). .

, -,
.
Na +. ,
ADH,
, 2
. , 2
(Posm) Na + .
ADH,
2 . H
,
. ,
10 L . , 2
2 ADH
2 2.
,

ADH. ,

. 2
Na+ .

-33-

H Na+

.
, Na + (
Na+ <50 mmol/L).
,
. , 2
,
(2
).

.
2,
(+, Na+) 2,
. 2
,
DH,
2
. ,
2,
2
2 ( ) ( 8).

-34-

8.

(
,
)

ADH: ADH,
,
Na+

: (+
),
(.. )
(reset osmostat syndrome):
, , , ,

ADH
2, ADH
.
ADH ,
, .
ADH
( ADH).
9.
9.

ADH

ADH
(, , , ,
, )
(, , .)
(, , , )

ADH
( )
DH
(, , , )
ADH
(, )

, Waldenstrom

-35-

: (1)
, (2) (>100 mosmol/kg), (3)
(>40 mmol/L), (4)
, , (5)
(6) .

.
: ()
() ADH
, , .
. ,
2 . ,
2 Na+
. ,
. Na+

.

Na+
.
(20-30 L) ,
.

, ,
Na+ .
7%.
,
.
(Posm) . Posm

-36-

.
2 Posm.
,
, ,
Na+, , 3 (
).
(
). H

(, ) Posm
, .
a+ Posm
2 . (, , ,
, , ) .
,
. ,
. ,

(+ Na+),
(, .),
.

.

.

( 10)
Posm, (Uosm) Na+ .

-37-

10.

Posm

<100 mosmol/kg

>100 mosmol/kg

<20 mmol/L

>40 mmol/L

ADH
Y

Uosm

Na+

Posm

, ,
,
Posm 2
Na+.
Uosm <100 mosmol/kg . A,
,
, Uosm
100 mosmol/kg. a+
.
Na+ (<20 mmol/L) ,
Na+ (>40 mmol/L)
ADH 10.

. , NaCl
2
. ,
NaCl. Na+
Na+ :
Na+ (mmol)= 0.6 x x (140 - Na+ )

-38-

(
Na+ 0.5 mmol/L/h 12 mmol/L/)
, a +

.
Na+ .
(.. , ),
,
(
), Na+ 2 .
,
()
.
ADH
Na+. ADH
NaCl .

.
2 ,
. Na +
130 mmol/L, Na +
25 mmol/48 h ( 12 mmol/24h)
<1 mmol/L/h. :
)

Na+ (130 mmol/L).

Na + (
mmol/L).

Na+
, Na +.

2
a+. mmol Na+,
a +
(130 mmol/L).

-39-

V)

mmol Na+ 514 (1L 3% NaCl 514

mmol Na+) (ml) NaCl
Na +
(130 mmol/L).

V)

NaCl (ml)

Na+
NaCl ( ml/h).

VI)

ADH (0.51 mg/kg ).
,
ADH. ,
NaCl
2 .

VII)

NaCl.

Na +,
,
NaCl.
ADH H2O,
Na+ , ,
DH , Li .


.
2. ,

.

-40)

Na+
2, 2 +
Na+ ( ).
,
ADH .
Posm
280 290 mosmol/kg, 2 Na+.

. ,

.
Na+ 60
,
.
11.
11.

2
) :
) :

) :
) :

) 2 :

(, , )

(, , )
(, ,
)

Na+
) NaCl NaHCO3
) Na+

: ()

, ,

-41-

()
( 12 13), .
,
, 2 , Na+,
.

12.

( , , Sheehans)
(.. ) (.. )
: , , , ,

13.

(Li, , , , )
Sjogren

Na+ Posm
2 . , (,
, , , , , )
.
,
. ,
,
,
(+, Na+, Cl-)
( ) .
Na +
. ( Na+)

-42-

2 .
2 2 Na+
. 2
:
Na+
2 = 0.5 x x

-1 (3)
140

( ,
0.4)
, 2

2 Na+ (..
).
0.5 mmol/L/h 12 mmol/L/24h
,
. , 2
( ) Na +
.

. ,
, 2, (
2 Na +),
2,
, NaCl. ,
2 a+ , ,
NaCl
.
, , .
5% NaCl,
. ,
(5%) (0.5-1 mg/kg).

-43-

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E I 1998; 15(1): 40-44.
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. E I 1999; 45-51.
, , , .
( ). 1989; 56: 265268.
, . .
2002; 3: 2-4.
, . .
2001; 2: 13-16.
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Med 1993; 94: 169-174.

-47-

+
)

+ . + 40-50
mmol/kg . 2%
, + 3.5 5 mmol/L. H
50-100 mmol + . 90%
+ ,
. , +.
,
, +
+,
+ .
+
, 50% + 4
. , +
. ,
+ . +
2
, Na+-K+-
. ,
. , ( )
+ ( 0.1-0.4
mmol/L 0.1 pH), (
) . ,
+
, .
+ (>90%)
Henle. +
. +
: ()
+, , ()
Na+,

-48-

, +, ()
+
()
.
)

14.
: () +, () +
, , 2
, 12
, () + (), (
, )
. + .

( CO 3-).
, +
,
HCO3-
. , Na+
( +
+) .

. ,
+ , ,
,
( , Bartter,
cisplatin ,
). ,
.

-49-

14.

K+
+ :

+:

, ,
(stress, , , ),
( ), 12

GM-CSF

,
(
), ,
* -

*
Na+, (..
, )+
Na+
(, ,
)
:

Bartter
(cisplatin, , )

+

,
:

. ,
(+ <3 mmol/L),
+
( , , , ,
, )
, (
, ,
, S-T
U). ,
,
(, , )
( , 3).

-50-

. ,
+
. , +
,
+ +
.
.
, Bartter.

, ,
. ,

+
.
+. +
, +
+. ,
,
+ . ,
+ 1 mmol/L + 200-400 mmol.
+ (
+) .
+,
. ,
KCl. +,
KCl . +
1L 40 mmol,
. ,
+ 20-40mmol/h. ,

+ (.. 200 mmol K+/L) 100 mmol/h
. (20 mmol

-51-

K+ 100 cc ) +.
+ (..
) ,
+ .
, .

15.
15.

+ :

(
, ,
)

-



-

+ :

(
)

+

: () +
, () +
, - , ,
,
, () + : (1)
, (2) , (3)

-52-

+
(4) ( 16).

16.

:


:
, ,


:
(, , -), *
( )
*
(20 mg/kg) (.. )
Pneumocystis carinii.

,
(PRA)
,
.
. , ,
+ (..
, -, .).
. ,

, ,

.

( IV).

-53-

+ 6.5-7 mmol/L. O
, ,
. (,
, ) +
8 mmol/L, + 6.5 mmol/L.
:
, S-T, R, P-Q,
P, QRS Q-T,
.
,

. ,
, .

+ ( + ).

+ ,
+ .
, ,
.
, + 7 mmol/L
.
. , +

,
+ , +
, .

. ,
.

+ .

-54-

Ca++ (10-20 ml 10%) 2-3

.
30. Ca++

, .
+
. + 15
. ,
. , 10
50 ml 50% (25 g ).
, 10 500 cc
10% 30-60. ,
10% ( 50 ml/h).
2
. , ( 8
).
+ 30. 2
. ,
(.. 44.6 mmol HCO3- 5),
(pH<7.20). , +
NaHCO3 . ,
NaHCO3 ,

.
(Kayexalate)
+ . 1 g
0.5-1 mmol K+ Na+

. 1-2 h 4-6 h.
.
.
15-30 g, 3-4
+ .

-55-

(50 g 200 ml 20%).
30-60 4-6 h.
,
.
,
.

-56-

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secondary

to

postsplenectomy

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-60-

. 60%
Mg++ , 40% . 1%
Mg++ . ,
Mg++ Mg++ .
Mg++ 0.65 -1.1 mmol/L.

17.
,
(cisplatin, , , ,
) Mg++.

17.

:
, , ,
Mg++ :




Mg++:
) :
Mg++
Bartter




) Mg++:
(, , cisplatin, -, , )
(, , -)
(, ,
, , )
* .

(
), ( P-R QT) (, , , , ,

-61-

).
. Mg++
.

. Mg++
. ,
Mg++ (>2 mmol/)
.

*.. Mg ++ (Trofocard)
5 mmol Mg++ 1 3 Mg++ (Mag2)
4.15 mmol Mg++/10 ml 1 3 +.
g++ .
3-7 ,
Mg++ * Mg++ (Trofocard) 2.5 mmol
Mg++/5 ml 4-5 1 lt 12 h Mg ++ (Mag2)
2.8 mmol Mg++/10 ml 2-3 1 L 12 h+.
Mg++
1.25 mmol/L. ,
, i
.

Y

Mg++,
MgSO4 .
Mg++ 2
mmol/L. (
, , ),
(, , , ,
P-Q Q-T, QRS).
Ca++ 10%, 10-20 ml 10,
Mg++.

-62-

.
o Mg++.
Mg++
( 150-200 ml/h).

-63-

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, .
. 2001; 80: 150-158.

-65-

Ca++
Ca++ o i .
99% Ca++ 1%
. Ca++ 8.9-10.3 mg/dl. 50% Ca++
( ) ,
.
Ca++, Ca++.

Ca++
Ca++ ( Ca++ = 4.6-5.1 mg/dl).
Ca++
D. Ca++ ,
Ca++
, D *1.25 (OH)2D3]
. Ca++ PTH
. , Ca ++
. D
. D
( 25) ( 1)
Ca++

. D
PTH
.

18.
. Ca ++
Ca++
* Ca++ 0.8 mg/dl 1g/dl
(4 g/dl)+
Ca++.

-66-

18.

, ,
, -

D:

, , ,
, ,
, ,

, , , ,
, , , cisplatin,
, , , foscarnet,
)
:
, , ,

Ca++ PO4- - - (hungry bone syndrome)

O
Ca++ .
Ca++ .

, , ,
. ,
Q-T .

Ca++ 10% (90 mg Ca++/10 ml); 2 amp (20 mg) i.v. 10
60 ml Ca++ 500 ml (1 mg/ml) 0.5-2 mg/kg/h.
Ca ++

8-9

mg/dl.

,
.
Ca++ (..
Mega Calcium 1 g 1.5-3 g/) D ( 50.000-100.000
/) Ca ++ 8-9 mg/dl. K
Ca++ .
(Ca++ 24 h>250 mg)
D,

-67-

Ca++ D. D
, .

19.

, Ca++ (
)
( ).
, Ca++ >12 mg/dl. : ()
, , ()
(, , , ) () (, ,
, ). ,
Q-T.
.
,
Ca ++.

19.

-
: , .
: , Li
D
-
Paget

: (1)
(3-4 L 24)
Ca++. ,
+ Mg++.

(20-40 mg 2-3 ), (2)

-68-

Pamidronate
(60-90 mg 1 lt 4 h).
, , ,
, (3) (4-8 IU/kg /6-12 h)
. ,
, (4) (20-50 mg 2),
, ,
D, (5) ,
,
, (6) (0.5-1 g
3)
<3 mg/dl.
,
NaCl (8-10 g/).

-69-

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-71-

. 85%
, . 1%
. ,
o .
3-4.5 mg/dl.
,
,
.
,
D ,
, .

20.
( <1 mg/dl),
, , ,
,

(hyperalimentation),

(refeeding)

, .

.,

.

-72-

20.

(.. Burkitt)

:
l Mg

:

*(>100 mg/
>20%+


D

Fanconi

<1 mg/dl . ,
( , ,
,
), (, , , ,
), (
).
. (
1-2.5 mg/dl)
.
(0.5-1 g 2-3
/). , ,
.
Ca++, . (
<1 mg/dl)

-73-

* 0.08-0.16 mmol /kg (2.5-5 mg

/kg) 500 cc /2 6 h+*. H 2436 h .
Ca++,
, 1.5 mg/dl
.
,
, , ,
. ,
, .

, , ,
( 21).

(, , ,
). , ,
.

21.

:
(
- )

D
:

:

(0.6-0.9 g/)
*CaCO3, Al(OH)3+.
*

12.54% 20 100 ml 0.33 mmol /ml.

-74-

Ca++
Ca++ <11 mg/dl Ca++ PO4- - -
60, .
Al(OH)3
.

.

-75-

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failure

association

with

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