83

Symposium on New Diagnostics

Evaluation of Renal Tubular Acidosis

Arvind Bagga and Aditi Sinha
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT
Renal tubular acidoses (RTA) comprises of a group of disorders characterized by a low capacity for net acid excretion and
persistent hyperchloremic, metabolic acidosis. The RTAs are classified into chiefly three types (types 1,2 and 4) based on clinical
and laboratory characteristics. Correct diagnosis involves careful evaluation, including exclusion of other entities causing
acidosis. A variety of tests are required to be administered in a stepwise fashion for the diagnosis and characterization of RTA.
[Indian J Pediatr 2007; 74 (7) : 679-686] E-mail : arvindbagga@ hotmail.com

Key words : Renal tubular disorders; Metabolic acidosis

Renal tubular acidosis (RTA) is a group of transport

defects secondary to reduced proximal tubular
reabsorption of bicarbonate (HCO 3-), the distal secretion
of protons (hydrogen ion, H +) or both, resulting in
impaired capacity for net acid excretion and persistent
hyperchloremic metabolic acidosis. In this review, we
discuss the pathophysiological basis and clinical and
laboratory diagnosis of this condition.
Physiology
The proximal renal tubule is the site of the bulk of solute
and water reabsorption in the nephron. Approximately
60% of the filtered sodium (Na +) is reabsorbed in the
proximal segments, along with water, potassium (K +),
bicarbonate (HCO3-), phosphate, amino acids and low
molecular weight proteins. In contrast, the distal tubule
has a specialized role in the final modification of urine
concentration and pH. Specialized transporters are
involved in the regulation of Na + and K+ reabsorption
and H+ secretion, which are shown in Figs. 1-3.

Pathophysiological basis
The proximal tubule is the major site for reabsorption of
filtered HCO 3 (Fig. 1). The primary defect in proximal
RTA is reduced renal threshold for HCO 3, resulting in
bicarbonaturia. The proposed mechanisms include
defective pump secretion or function of the H + ATPase,
the Na+/H+ antiporter, the Na+/K+ ATPase or deficiency
of carbonic anhydrase in the brush-border membrane.
Proximal RTA may represent isolated or generalized
proximal tubular dysfunction, the latter (Fanconi
syndrome) characterized by tubular proteinuria and
aminoaciduria and variable degrees of bicarbonaturia,
phosphaturia, Na + and K+ wasting and glucosuria. K+
wasting is enhanced due to increased distal tubular
delivery of Na + and hyperaldosteronism secondary to
volume contraction.

Classification of RTA
Based on pathophysiology, RTA has been classified into
three types: type 1 (distal) RTA; type 2 (proximal) RTA;
and type 4 RTA secondary to true or apparent
hypoaldosteronism. The above conditions are either
secondary to other causes,1 or primary, with or without
known genetic defects.

Correspondence and Reprint requests : Dr. Arvind Bagga,

Department of Pediatrics, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110029, India.
[Received January 24, 2007; Accepted February 2, 2007]

Indian Journal of Pediatrics, Volume 74July, 2007

Fig. 1. Bicarbonate absorption in the proximal tubule. The secreted

H+ combines with luminal HCO 3- to form H 2CO 3, which,
under the action of carbonic anhydrase (CA) dissociates to
H2O and CO2. The CO2 travels across the membrane into the
cell where it combines with OH- to generate HCO3-; HCO3and Na + cross the basolateral membrane using the Na +/
HCO3 - symporter. Na+ also exits the cell via the Na +/K +
ATPase.

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A. Bagga and A. Sinha

Fig. 2. Mechanism of distal acidification. Intercalated cells in distal

tubule mediate HCO3 - absorption through secretion of H+
through H+ ATPase and H+/K+ ATPase. The hydroxyl (OH-)
ions generated in the cell through H+ secretion exit the cell by
the HCO3 -/Cl- exchanger. The secreted H+ is buffered by
luminal ammonia forming NH4 + and phosphate (titrable
acids), to prevent a drop in luminal pH that would prevent
further H+ secretion.

Fig. 3. Sodium transport in the principal cells. The apical membrane

of the principal cells contains an amiloride sensitive Na +
channel, which transports Na + into the cell that exits
basolaterally via Na+/K + ATPase. Na+ transport creates a
lumen negative transepithelial potential that increases the
rate of H + secretion (by intercalated cells). (Fig. 2).
Aldosterone enhances Na+ absorption and increases H + and
K+ secretion.

Metabolic acidosis secondary to decreased secretion of

H + ions in the absence of marked decrease in the
glomerular filtration rate is characteristic of distal RTA.
Patients with distal RTA are unable to excrete
ammonium (NH 4+) ions in amounts adequate to keep
pace with a normal rate of acid production. In
hypokalemic distal RTA, urine pH cannot reach maximal
acidity (i.e., remains >5.5) despite systemic acidemia
indicating low H+ concentration in the collecting duct. In
hypokalemic distal RTA, also known as classic RTA or
type 1 RTA, the deficiency is secondary to either a
secretory (rate) defect or a gradient (permeability) defect.
In the secretory defect, the rate of secretion of H+ is low
for the degree of acidosis. Ideally, with a rate defect the
ability to maximally acidify the urine should be retained.
680

However, with a severe rate defect, the time spent in

tubule lumen may be insufficient for acidification, and
there is failure to maximally decrease the urine pH. The
defect in secretory distal RTA may be secondary to
defective function of H+ ATPase, H+/K+ ATPase, or the
Cl - /HCO 3 - exchanger. Patients with the gradient
(permeability) defect show normal secretory capacity of
H+ but an increased backleak resulting in dissipation of
the pH gradient. A subtype exists, where the backleak is
due to enhanced membrane permeability to HCO3-, as
seen with amphotericin induced RTA. In distal RTA, the
titrable acidity and NH4 + secretion is low resulting in
systemic acidosis. The cause of hypokalemia is attributed
to increased K+ loss in the tubular lumen, urinary Na+ loss
and volume contraction leading to aldosterone
stimulation that increases tubular K + secretion, and
decreased proximal K+ reabsorption.2 Incomplete distal
RTA is a variant or milder form of classic distal RTA, in
which there is defective tubular H + secretion but plasma
HCO3 - levels are normal. Daily net acid excretion is
maintained
by
enhanced
ammoniagenesis.
Hypercalciuria and hypocitraturia are present, and there
is a risk for nephrolithiasis and nephrocalcinosis.
Distal RTA associated with hyperkalemia may occur
due either to a voltage-defect or rate-defect due to
aldosterone deficiency or resistance. The voltage-defect is
uncommon and caused by an insufficient negative
intratubular potential at the level of cortical collecting
duct (Fig. 3), which results in reduced secretion of H+ and
K+, with decreased trapping and excretion of NH 4+ and
hyperkalemia. Inadequate voltage generation may be due
to drugs such as amiloride that inhibit Na+ transport in
the cortical collecting tubules, structural defects that
inhibit active Na + reabsorption in the tubules such as
sickle cell nephropathy and obstructive uropathy, and
increased epithelial permeability to Cl - causing its
reabsorption and attenuating the negative voltage linked
to Na+ reabsorption. The laboratory parameters in the
voltage-defect (hyperkalemic distal RTA) resemble classic
distal RTA, except for the presence of normo- or
hyperkalemia (Table 2).
More commonly, hyperkalemia with distal RTA is due
to aldosterone resistance or deficiency (type 4 RTA).
Aldosterone increases Na + absorption and results in a
negative intratubular potential (Fig. 3). It also increases
luminal membrane permeability to K+ and stimulates
basolateral Na+/K+/ATPase, causing increased urinary
K+ losses. Since aldosterone also directly stimulates the
proton pump, aldosterone deficiency or resistance is
expected to cause hyperkalemia and acidosis. Another
major factor in decreasing net H+ excretion in type 4 RTA
is the inhibition of ammoniagenesis due to hyperkalemia.
In type 4 RTA, maximally acidic urine (<5.5) can be
formed, indicating the ability to establish a maximal H+
gradient. However, despite the maximally acidic urine,
the rate of ammonium excretion is low.2
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Evaluation of Renal Tubular Acidosis

When should RTA be suspected?
Clinical features that suggest RTA include growth
retardation, failure to thrive, polyuria, polydipsia,
preference for savory foods and refractory rickets.
Children with proximal RTA often present with stunted
growth. Rickets and/or osteomalacia may be associated,
and suggest the presence of Fanconi syndrome.
Nephrocalcinosis and urolithiasis are not seen. Symptoms
related to hypokalemia including weakness and paralysis
are uncommon. In children, proximal RTA occurs either
as a primary isolated defect or as part of Fanconi
syndrome secondary to cystinosis, galactosemia, fructose
intolerance, tyrosinemia, Wilson disease or Lowe
syndrome.1,3
Clinical features in distal RTA include impairment of
growth, polyuria, nephrocalcinosis, nephrolithiasis and
symptoms due to hypokalemia. Progression of
nephrocalcinosis may lead to chronic renal failure. In
children, distal RTA is almost always observed as a
primary entity. Rarely, it occurs as a complication of
systemic lupus erythematosus or Sjogren syndrome. A
proportion of cases with sporadic or autosomal recessive
distal RTA show sensorineural deafness, which may be
present from birth or manifest in late childhood.
Type 4 RTA is associated with hypoaldosteronism or
resistance to the action of aldosterone, either isolated or
in the context of chronic kidney disease, for example
obstructive uropathy. Nephrocalcinosis and urolithiasis
are absent and bone lesions are rare. Older children may
develop type 4 (RTA) due to advanced tubulointerstitial
renal diseases leading to mineralocorticoid resistance,
drugs, or with mineralocorticoid deficiency. Pseudo hypo
aldosteronism (PHA) type 1 is characterized by saltwasting, hyperkalemia and metabolic acidosis in the
presence of markedly elevated plasma renin activity and
aldosterone concentration. PHA type 2 is an autosomal
dominant syndrome of arterial hypertension,
hyperkalemia, metabolic acidosis, and suppressed
plasma renin activity.4
Evaluation of RTA
Metabolic acidosis may result from extra-renal processes,
which result in either increased endogenous acid synthesis (e.g., ketoacidosis) or enhanced extra-renal bicarbonate
wasting (diarrhea). Intestinal and pancreatic secretions
and bile have considerable quantities of HCO3; therefore,
conditions like diarrhea, removal of pancreatic or
intestinal secretions or bile by tube drainage or fistula
leads to loss of HCO 3 - and metabolic acidosis. 5
Hyperchloremic metabolic acidosis may also result from
ureterosigmoidostomy due to presence in the colon of an
anion exchange pump that absorbs luminal Cl- (of urinary
origin) and exchanges it for HCO3-, and due to colonic
absorption of NH4+ (of urinary origin), which releases H+
when metabolized in the liver. Drugs like cholestyramine
Indian Journal of Pediatrics, Volume 74July, 2007

also cause metabolic acidosis by acting as anion exchange

resins, where colonic luminal HCO 3 - is absorbed in
exchange for Cl- released by the resin.6 RTA may be due
to either HCO 3- wasting (proximal RTA) or inability to
generate new HCO 3- to buffer endogenous acid (distal
RTA). Na+ wasting (as NaHCO3 or as salt of other acids)
results in volume contraction and increased avidity of
renal Cl- absorption, causing hyperchloremia and normal
anion gap acidosis.
Since all types of RTA are associated with normal
anion gap, the initial step in the evaluation of metabolic
acidosis is to determine the plasma anion gap.
Step 1. Determine plasma anion gap
Plasma anion gap is calculated as follows:
Anion gap = [Na+] {[Cl] + [HCO3]}
The normal plasma anion gap is 8-16 mEq/L. Important
causes of metabolic acidosis with normal anion gap
include RTA and diarrhea (Fig. 4). An elevated anion gap
suggests conditions associated with excess unmeasured
anions, e. g., diabetic ketoacidosis, lactic acidosis due to
shock or poor peripheral perfusion, some inborn errors of
metabolism, poisonings and uremia. While advanced
renal failure with GFR <15 ml/min results in metabolic
acidosis with elevated anion gap, normal anion gap
(hyperchloremic) acidosis is not infrequent at GFR 20-50
ml/min, especially in patients with tubulointerstitial
diseases.7
Step 2. Estimate urine anion gap (UAG)
Having established the presence of metabolic acidosis
with a normal plasma anion gap, the next step is to
distinguish renal (RTA) from extra-renal causes.
Halperin, et al proposed UAG (or urine net charge) for
estimating NH 4 + excretion in patients with
hyperchloremic metabolic acidosis.8 The test is based on
the assumption that while metabolic acidosis due to
extrarenal HCO3 losses (diarrhea) is associated with high
urinary NH4+ excretion, the excretion is low in patients
with RTA. Since the sum of charges on cations and anions
is equal,
Na + + K + + NH 4+ + unmeasured cations = Cl +
unmeasured anions
The difference between urinary unmeasured anions
(sulfates, phosphates, organic anions) and cations
(calcium, magnesium) is relatively constant at an
approximate value of 80, therefore
Na+ + K+ + NH4+ = Cl- + 80, or
NH4+ = 80 (Na+ + K+ - Cl-)
UAG or urine net charge is the difference between the
sum of urinary Na+ and K+ and Cl. Hence, the UAG gives
an approximate estimate of urinary NH4+ excretion.
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A. Bagga and A. Sinha

Anion Gap

Normal anion gap (hyperchloremic)

High anion gap

Renal origin

Extrarenal origin

Renal origin

Renal tubular acidosis

Mild renal insufficiency
GFR >15 ml/min

Uremic acidosis
Lactic acidosis
GFR <15-20 ml/min Diabetic ketoacidosis
Starvation ketoacidosis
Poisoning by ethylene
glycol, methanol or
salicylates

Extrarenal origin

Diarrhea
Ureterosigmoidostomy
Pancreatic or biliary losses
Drugs e.g., cholestyramine,

Fig. 4. Differential diagnosis of the causes of metabolic acidosis. GFR glomerular filtration rate
+
4

NH = 80 UAG

and glucose are in mg/dl).

Under normal circumstances, the UAG is positive due

to the presence of dissolved anions. Metabolic acidosis
with normal mechanism of renal acidification causes the
UAG to become negative due to an increase in the NH4+
synthesis and excretion with the Cl ion. Thus in patients
with hyperchloremic metabolic acidosis with preserved
mechanism of renal acidification a negative UAG implies
adequately increased NH 4+ excretion. A positive UAG
indicates inappropriately low renal NH4+ excretion, as in
RTA. While initial reports suggested normal excretion of
urinary NH4+ (negative UAG) in subjects with proximal
RTA, recent studies show that both proximal and distal
RTA are characterized by inappropriate levels of urinary
NH4+, and thus a positive UAG.
There are two caveats in the above approximations.
First, the UAG approximates NH 4+ excretion only in
patients with chronic hyperchloremic metabolic acidosis.
Second, the validity of this value in estimating NH 4+
excretion is limited if the urine pH>6.5, since HCO3 is
then a significant urinary anion (but is not included in
calculation of the UAG). In presence of significant other
anions (e.g., ketones, HCO3) or cations (e.g., lithium) the
reliability of UAG is limited. Here, the measurement of
urine osmolal gap is more useful than the UAG in
estimating urinary NH4+ excretion. The osmolal gap is
determined as follows:
Urine osmolal gap = measured osmolality calculated
osmolality
The early morning urine osmolality is measured
directly by an osmometer and calculated as given below:
Calculated urine osmolality = 2 [Na+ + K+] + urea + glucose

18

(Urinary levels of electrolytes are in mEq/l and urea

682

Urinary NH4+ excretion, estimated at half the urine

osmolal gap, is considered appropriately increased if the
gap >100 mOsm/Kg.
Step 3. Determine urine pH
Urine pH is useful for assessing the overall integrity of
distal urinary acidification. In the presence of systemic
acidosis, present spontaneously or induced by
ammonium chloride load, the urine pH is normally <5.5.
Presence of urine pH >5.5 during metabolic acidosis
suggests defective distal secretion of H +. It should
however be appreciated that the urine pH measures the
concentration of free H+ in the urine. This constitutes <1%
of the total amount of H+ secreted in the distal nephron
during systemic acidosis, since most protons are excreted
as NH4+ or titrable acidity. Urine pH values < 5.5 are seen
in subjects with proximal RTA during systemic acidosis
and low filtered load (plasma HCO 3 <15 mEq/L), or in
patients with selective aldosterone deficiency.
If systemic acidosis is absent, an oral ammonium
chloride challenge (0.1 mg/Kg) might be given, followed
by the measurement of urine pH every hr for the next 28 hr. If the plasma total CO2 content falls by 3-5 mEq/L,
the urine pH should fall to <5.5. Another protocol
involves giving the same dose of ammonium chloride
daily for 3-5 days, followed by measurement of urine pH
and urinary NH4+ excretion; the latter should increase 35 times the baseline by the third day of induced acidosis.
In patients with liver disease, calcium chloride may be
used as an acidifying agent at a dose of 2 mEq/Kg.
The pH is measured electrometrically on fresh voided,
early morning urine specimen. The use of dipstick is not
recommended. Urine kept standing is likely to get
contaminated or infected with urea-splitting organisms,
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Evaluation of Renal Tubular Acidosis

resulting in high urine pH. The urine pH must be
evaluated in conjunction with the urinary NH4+ content to
assess the acidification process. Low urine pH does not
always imply an intact urinary acidification mechanism,
if excretion of NH4+ is low, as might occur in proximal
RTA.
Patients with chronic metabolic acidosis (e.g., after
chronic diarrhea) show increased ammoniagenesis that
consumes most distally secreted H + ions, resulting in
enhanced urine NH 4 + excretion. The urine pH in this
instance may therefore be high despite appropriate H+ excretion.
Urine pH should also be interpreted in relation to urine
Na+ levels. When urine Na+ level is <5-10 mEq/l, distal
H+ secretion is low; high urine pH therefore might not
imply a defect in distal urinary acidification in subjects
with low urinary Na+ concentration.
Step 4. Bicarbonate loading test
Sodium bicarbonate is administered as half-strength IV
infusion (0.5 mEq/ml) at the rate of 3 ml/minute through
a peripheral vein, while measuring urine pH in timed
samples taken 30-60 minutes apart. The urine should be
collected under mineral oil, with the child voiding in the
upright position. A steady state is usually achieved after
3 to 4 hr of start of infusion, and the test is terminated
when three samples of timed urine collections show urine
pH >7.5. The medication may also be given orally at a
dose of 2-4 mEq/Kg/day for 2-3 days, with the aim to
achieve a similar urine pH and/or normal plasma pH
and HCO 3 -. Interpretation of this test allows
characterization of the type of RTA.

With a urine phosphate concentration above 20 mmol/L,

normal subjects should achieve a urine-to-blood PCO 2
gradient above 40 mmHg.
Fractional excretion of bicarbonate (FEHCO3)
This is an important index of proximal tubular handling
of HCO 3 . The FEHCO 3 is calculated after adequate
alkalization. The proximal tubule normally reabsorbs
almost all filtered bicarbonate (fractional excretion <5%).
urine bicarbonate plasma creatinine
FEHCO3 (%) =

plasma bicarbonate urine creatinine

When the serum bicarbonate is normal (>22 mEq/l), a

value >15% indicates proximal RTA. Levels are in the
normal range (<5%) in classic distal RTA although HCO3absorption is incomplete at low levels of plasma HCO 3-,
its absorption increases with increasing levels. In
hyperkalemic distal RTA, the FEHCO3 varies from 5-10%.
Despite normal proximal HCO3- reabsorption, variable
degrees of fixed bicarbonaturia may occur in type 1 RTA
due to the high urine pH, because the urine HCO3- varies
with the urine pH as per the Henderson Hasselbach
equation.
log HCO3Urine pH = pKa +
0.03 pCO2
Thus, even in type 1 RTA with urine pH <6, the
FEHCO3 is 3%, while at urine pH >7 it may exceed 5-10%.
This is referred to as type 3 RTA; it does not indicate the
co-presence of a proximal defect in HCO3- reabsorption,
unlike previously proposed.

Urine to blood CO2 gradient

Step 5. Additional Investigations

In alkaline urine, such as after a load of sodium

bicarbonate, urine PCO 2 increases because of distal H+
secretion and is considered a sensitive indicator of distal
acidification. The secreted H+ in the distal tubule reacts
with luminal HCO 3 - to form carbonic acid, which
dehydrates slowly in the medullary collecting duct to
form CO2 that is trapped in the renal tubule. If urine pH
is >7.5 and plasma HCO3- concentration >23-25 mEq/L,
the urine PCO2 should exceed 70 mm Hg and the urineto-blood PCO2 gradient should be greater than 20 mm Hg
in normal individuals. Patients with decreased rates of
tubular H + secretion (classical type 1 RTA) show
subnormal values, with urine PCO 2 less than 50 mm Hg
and U-B PCO2 <10 mm Hg. Those with backleak distal
RTA retain the ability to generate high urinary PCO2,
because the proton pump function is normal and the H+
gradient does not favor back-diffusion during alkaline
diuresis. Normal results are also observed in
hypoaldosteronism associated RTA and reversible
voltage-dependent defects.

Tests for phosphate handling

Urine PCO2 also augments markedly after neutral

phosphate administration, providing that urine pH is
close to the pK of the phosphate buffer system (i.e., 6.8).
Indian Journal of Pediatrics, Volume 74July, 2007

100

The plasma phosphate level indicates proximal tubular

function. The fractional excretion of phosphate
determined on a timed (6-hr, 12-hr, 24-hr) urine
specimen, is useful for detecting phosphate wasting,
which provides supportive evidence for presence of
proximal RTA, as in Fanconi syndrome. Normally 5-12%
of the ultrafiltered phosphate is excreted and the tubular
reabsorption is 88-95%.
Fractional excretion =
of phosphate

urine phosphate plasma creatinine

100
plasma phosphate urine creatinine

Tubular reabsorption = 100 - fractional excretion

The tubular reabsorption of phosphate depends on
plasma phosphate and GFR and is not the optimal
indicator of tubular phosphate handling, especially in
patients with hypophosphatemia. This has led to
increasing use of the index, tubular maximum for phosphate,
corrected for GFR (TmP/GFR), a factor independent of
plasma phosphate and renal functions for assessment of
phosphate handling. TmP/GFR, or Bijvoet index,
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A. Bagga and A. Sinha

2.0

0.2

1.8

0.4

1.6

5.0

4.0
1.4

0.6
2.0

0.8
1.0

3.0

1.2
1.4

1.0

1.8
2.0

1.2

3.0

1.0
0.8

2.0

0.6

0.4

1.0

0.0

0.0

1.
00

5.0

1.6

0.
01
0.
0
5
0.
0.
10
99
0
0.
0. .20
9
5
0. 30
0.
90
0. 40
0.
50
8
0
0
0.
.
7
60
0. 0
0.
0. 60
70
50
0.
0.
80
40
0.
30
0.
90
0.
20
0.
10
0.
00

Actual plasma phosphate concentration (mg/dL)

1.0

0.0

Renal threshold phosphate concentration (TmP/GFR)

0.
00

0.0

0.
00

represents the concentration above which most

phosphate is excreted and below which most is
reabsorbed. 9 It can be calculated from the plasma
phosphate and TRP (on timed urine samples) using
Bijvoet nomogram (Fig. 5) or directly:

Fig. 5. Assessment of TmP/GFR involves estimation of plasma

phosphate (left y-axis) and tubular reabsorption (TRP) (or
fractional excretion, C p/Ccr ). The straight line joining these
values is extended to obtain TmP/GFR (right y-axis).
TmP/GFR (mg/dL) =
plasma phosphate

urine phosphate plasma creatinine

urine creatinine

The normal value of TmP/GFR is 2.8-4.4 mg/dL, with

lower values in older children.
Transtubular potassium gradient (TTKG)
While spot and 24-hr urinary excretion of K+ is useful for
evaluating patients with hypokalemia, its role in
evaluating subjects with hyperkalemia is limited. In
patients with hyperkalemia and normal glomerular
function, the TTKG provides an accurate estimate of
aldosterone effect on late distal and cortical collecting
tubules, as explained below.

Briefly, secretion of K + in the cortical and outer

medullary collecting ducts accounts for the majority of its
excretion in the urine that is influenced by aldosterone,
plasma K+ concentration and anion composition of the
luminal fluid. Negligible amounts of K + are secreted or
reabsorbed distal to these sites. The final urinary K+
concentration then depends on water reabsorption in the
medullary collecting ducts, which results in a rise in the
final urinary K+ concentration. TTKG is determined as
follows:
TTKG =

urine K+ x plasma osmolality

plasma K+ x urine osmolality

The ratio of urine to plasma osmolality allows for

correction of the final urinary K+ concentration for the
water reabsorbed in the medullary collecting duct. The
TTKG is an index of the gradient of K + in the distal
tubular lumen and interstitial blood capillaris,
independent of urine flow rate.
The urine must at least be iso-osmolal with respect to
serum if the TTKG is to be meaningful. The TTKG in
normal persons varies but is generally within the range of
6-12. Hypokalemia from extrarenal causes results in renal
K+ conservation and a TTKG <2. A higher value suggests
renal K + losses, as in hyperaldosteronism. During
hyperkalemia, the expected TTKG is >10. An
inappropriately low TTKG (< 8) in hyperkalemia
suggests hypoaldosteronism or renal tubular resistance to
aldosterone. Administration of the mineralocorticoid,
fludrocortisone (0.05 mg) enables TTKG to rise to >7 in
patients with hypoaldosteronism. When the TTKG does
not increase after mineralocorticoid challenge, tubular
resistance to aldosterone is suspected.10
Frusemide test
Response to frusemide and sodium sulfate help
determine the mechanism of defect in type 1 RTA (Table
1). Responses to frusemide or sodium sulfate help
elucidate the possible site and mechanism of acidification
defect in type 1 RTA. Both agents tend to increase the
luminal electronegativity by increasing Na+ delivery to
and reabsorption in the cortical collecting tubule. The
changes that these agents induce in H+ and K+ excretion in
normal subjects, and in those with various defects of
distal RTA, are shown in Table 1. In healthy individuals

TABLE 1. Response of Urine pH and Potassium (K+) Excretion Following Frusemide Administration in Normal Subjects and Various
Defects Causing Distal RTA.
Defect

Normal
H+ ATPase defect
H+ ATPase defect
Voltage defect

Site of defect

None
Diffuse, cortical CT
Medullary CT alone
Cortical CT

Urine pH
During acidosis
After frusemide
<5.5
>5.5
>5.5
>5.5

Further decline
>5.5
<5.5
>5.5

K+ excretion
Baseline
After frusemide
Normal
Normal
Normal
Decreased

Increased
Increased
Increased
Unchanged

CT collecting tubule

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Evaluation of Renal Tubular Acidosis

administration of either of these agents results in decrease
in urine pH to <5.5 and increased K+ excretion.
In patients with hypokalemic distal RTA, due to defect
in the H+ ATPase, the urine pH does not fall but the urine
K+ excretion increases, in response to frusemide since the
function of principal cells is intact. Patients with H +
ATPase pump defect limited to the medulla show a
relatively normal increase in both H + and K+ secretion
because cortical tubule function is stimulated
appropriately by a rise in luminal electronegativity.
Patients with primary defect in cortical Na+ reabsorption
(voltage defect) have baseline hyperkalemia and no posttherapy increase in H + or K + excretion, since luminal
electronegativity is not enhanced. A normal response is
observed in patients with type 4 RTA, hypoaldosteronism
(where voltage sensitive activity is retained), reversible
voltage dependent defects (as with lithium-induced RTA)
and proximal RTA.6
The sodium sulfate test is limited to research settings.
The frusemide test is practical and can be done using the
agent at a single oral dose of 2 mg/Kg body weight, after
collecting baseline sample of urine. Hourly urine samples
are collected and urine pH and K + concentration
determined. Some protocols involve the administration of
an oral dose of fludrocortisone (1 mg) the evening prior to
testing.2

work-up should always include ultrasonography for

nephrocalcinosis and renal calculi, and measurement of
urinary calcium and citrate excretion. Hypercalciuria and
hyperphosphaturia occur due to the release of calcium
phosphate from bone in order to buffer excess H + during
acidosis, and the direct effects of acidosis on tubular
reabsorption of these ions. Hypocitraturia results from
increased citrate utilization in proximal tubule cells due
to intracellular acidosis, resulting in an increased gradient
for tubular reabsorption, and due to the high luminal pH
favoring conversion of citrate3- to the readily reabsorbable
citrate2-. Hypercalciuria, hypocitraturia and high urine
pH contribute to occurrence of calcium phosphate renal
stones. Hypercalciuria is suspected when the value of
urinary calcium to creatinine ratio is above the age related
norm, and diagnosed in the presence of 24-hr calcium
excretion exceeding 4 mg/Kg/day. Hypocitraturia is said
to be present when the 24 hr urinary citrate is below 2
mg/Kg/day.9

Table 2 summarizes the results of invertigations in

different forms of RTA.

All patients with idiopathic distal RTA should

undergo a formal hearing evaluation, in view of the
association of sensorineural deafness with recessively
inherited disease; deafness may not be present in infancy
and develop later. Since type 1 RTA in older children may
be associated with systemic lupus erythematosus, Sjogren
syndrome or chronic hepatitis, appropriate evaluation for
these entities should be undertaken. A subtype of type 1
RTA, caused by deficiency of carbonic anhydrase type II
isoenzyme, is associated with osteopetrosis.2

Proximal RTA

Type 4 RTA

The diagnosis of proximal RTA calls for study of other

proximal tubular functions. Assessment of phosphate
excretion has been discussed above. Evaluation for
aminoaciduria, glucosuria and rickets is important.
Disorders that are associated with proximal RTA and
Fanconi syndrome should be specifically screened for,
including cystinosis, Lowes syndrome, galactosemia and
Wilsons disease.1

In children, aldosterone unresponsiveness is a more

common cause of type IV RTA than aldosterone
deficiency, and is commonly associated with obstructive
uropathy. Diagnostic work-up should thus include
investigations for an underlying nephropathy, including
ultrasound to identify structural abnormalities and renal
function tests for parenchymal dysfunction. TTKG is
useful in diagnosing type 4 RTA, and when done before
and after a mineralocorticoid challenge helps distinguish
between deficiency and resistance to aldosterone. Plasma
renin activity and aldosterone levels are necessary.

Distal RTA
When a diagnosis of distal RTA is made the diagnostic

TABLE 2. Investigations to Differentiate Types of Renal Tubular Acidosis (RTA)

Proximal RTA
Plasma K+
Urine pH
Urine anion gap
Urine NH 4+
Fractional HCO3- excretion
U-B PCO 2 mm Hg
Urine Ca 2+
Other tubular defects
Nephrocalcinosis
Bone disease

Normal/low
< 5.5
Positive
Low
>10-15%
>20
Normal
Often present
Absent
Common

Distal RTA

Type 4 RTA

Classic

Hyperkalemic

Normal/low
> 5.5
Positive
Low
<5%
< 20
High
Absent
Present
Often present

High
> 5.5
Positive
Low
<5%
</>20
High
Absent
Present
Uncommon

High
< 5.5
Positive
Low
5-10%
>20
Normal/low
Absent
Absent
Absent

U-B PCO 2 urine to blood PCO2 gradient.

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A. Bagga and A. Sinha

Hyperchloremic (normal anion gap) Metabolic Acidosis

Urine anion gap

Negative

Positive

Gastrointestinal losses
Acid intake

Suspect RTA

Urine pH
Serum K+
Sodium bicarbonate loading

Urine pH <5.5
Serum K+ low normal
UB CO2 >20 mm Hg
FEHCO3 >10-15%
Proximal RTA

Screen for other

proximal tubular defects

Urine pH >5.5
Serum K+ low/normal
UB CO2 <20 mm Hg
FEHCO3 < 5%
Classic type 1 RTA
(Secretory defect)

Urine pH >5.5
Serum K+ high/normal
UB CO2 </>20 mm Hg
FEHCO3 <5%

Hyperkalemic type 1 RTA

(Voltage defect)

Screen for hypercalciuria &

nephrocalcinosis

Urine pH <5.5
Serum K+ high/ normal
UB CO2 >20 mm Hg
FEHCO3 5-10 %
Type 4 RTA

Screen for renal

parenchymal disease
Plasma renin &
aldosterone

Fig. 6. Evaluation of a patient with renal tubular acidosis. GI: gastrointestinal, U-B CO2: urine to blood PCO2 gradient, FEHCO3 fractional
excretion of HCO3-

Genetic studies
Recently, mutations have been identified in the genes
encoding a number of transporters involved in
pathogenesis of RTA and PHA types 1 and 2. 2,11,12
Identification of these mutations provides insights into
the pathogenesis of RTA, but are currently available only
as research tools.
The evaluation of patients with RTA requires
understanding of basic concepts and a methodological
approach, as outlined in Fig. 6.
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Indian Journal of Pediatrics, Volume 74July, 2007