c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8

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Review Article

Renal tubular acidosis

Gopal Basu*, Golla Sudhakar, Anjali Mohapatra

Department of Nephrology, Christian Medical College, Vellore 632004, Tamil Nadu, India

article info abstract

Article history: Renal tubular acidosis is a collection of renal tubular disorders of diverse etiopathological
Received 15 October 2013 states that present with hyperchloremic metabolic acidosis due to failure of net renal acid
Accepted 22 November 2013 excretion. This review attempts to simplify the underlying physiological basis, the path-
Available online 15 December 2013 ophysiological patterns, and the clinical manifestations. An algorithmic approach to di-
agnose RTA along with a description of most of the tests used is provided. The clinical
Keywords: approach to RTA is followed by a brief note on its therapy.
Renal tubular acidosis Copyright ª 2013, Reed Elsevier India Pvt. Ltd. All rights reserved.
Proximal
Distal
Hypokalemia
Hyperkalaemia

1. Introduction 2. Physiologic renal handling of acid base

Renal tubular acidosis is a collection of renal tubular disorders
of diverse aetiolopathological states that present with hyper-
chloremic metabolic acidosis due to failure of net renal acid
excretion. Renal acid excretion is impaired by an inability
either to conserve bicarbonate or to excrete the Hþ ions. Renal
tubular acidosis (RTA) commonly manifest with polyuria,
polydipsia, renal calculi, failure to thrive, growth retardation,
and musculoskeletal abnormalities. First described in 1935,1 it
was confirmed as a renal tubular disorder in 1946.2 The term
“renal tubular acidosis” was designated in 1951.3 The disease
most often affects children, making it imperative to diagnose
and treat it effectively to preserve growth potential and pre-
vent ill-effects of systemic metabolic acidosis. In this article
we review the pathophysiology and clinical approach to RTA,
with a brief note on its therapy.
balance
The average Hþ generated by the adult diet amounts to
50e100 mmol/day (0.75e1.5 mmol/kg body weight) and this
daily load is excreted by the kidney. The mechanisms of acid
excretion vary by tubular segment. Firstly, the necessity to
excrete a net acid load indicates the need for all of the filtered
bicarbonate (4500 mmol/day) to be reabsorbed. Secondly,
excretion of 50e100 mmol/day of acid as free Hþ ions would
result in lowering the urine pH to 1.0. As the lowest physio-
logical urine pH is w4.2, and the average urine pH is 6.0, the
excretion of Hþ ion is aided significantly by luminal buffering.
The quantitatively important buffering agents in the renal
tubule (other than bicarbonate) include ammonia and phos-
phate. The net effect of secretion of each Hþ ion is associated
with the generation of one HCO3- ion in the plasma.

* Corresponding author. Tel.: þ91 41 62282053; fax: þ91 41 62232035.

E-mail addresses: drbasug@yahoo.co.in, drbasug@cmcvellore.ac.in (G. Basu).
2211-9477/$ e see front matter Copyright ª 2013, Reed Elsevier India Pvt. Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.cqn.2013.11.006
 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
Conversely, with every HCO3- lost in the urine, there is addi-
tion of one Hþ ion to the plasma, reducing the net acid
excreted. Thus, the net acid excretion by a normal individual
in urine is expressed by the equation:
   


NAE ¼ ½TA þ NHþ
4 U HCO3 U  V
where NAE is the net acid excretion, TA is titrable acidity, and
the urine V is the urine flow rate.
The titrable acidity is defined as the acid load excreted
(predominantly by phosphate buffer) and determined by the
amount of alkali required to bring the urine pH to 7.4.
While on a standard diet, the usual bicarbonate excretion is
negligible, NHþ
4 excretion is 50e60 mmol/day (about 15% of
maximum capacity) and titrable acidity is 20e30 mmol/day
(about 40% of maximum capacity).4 In systemic acidosis of
non-renal origin, the net acid excretion can exceed 300 mmol/
day, primarily by an enhanced NHþ
4 secretion and subsequent
reduction in pH of the urine. During alkalosis, the net acid
excretion can become negative, by increasing the quantity of
HCO-3 lost in urine, thereby increasing the urine pH. These
changes are considered “appropriate” responses of kidney in
the respective acid base disturbances.
Proximal tubular acidification of urine is achieved predom-
inantly by bicarbonate reabsorption and to a small extent acid
secretion. The PCT reclaims up to 80e85% of filtered bicarbon-
ate (w4300 mmol per day), thereby contributing to the reduc-
tion in the final bicarbonate concentration in urine to negligible
amounts. The major players in PCT bicarbonate reabsorption
are luminal Naþ/Hþ exchanger (NHE3), brush border carbonic
anhydrase IV (CA-IV), cytoplasmic carbonic anhydrase II (CA-
II), basolateral Naþ-3HCO-3 cotransporter (NBC1) and the Naþ/
Kþ ATPase. The negative potential generated by low intracel-
lular sodium concentration due to the Naþ/Kþ ATPase activity,
favors sodium reabsorption which is coupled to Hþ secretion by
Fig. 1 e Proximal Tubular Cell pathways of acidification.
167
the NHE3. Two-thirds of PCT Hþ secretion is by NHE3 while the
rest one-third is by the Hþ ATPase on the luminal side.5,6 The
secreted Hþ combines with luminal HCO-3 with help of luminal
CA-IV forming carbon dioxide and H2O. CO2 diffuses into the
PCT cell through the luminal membrane and is rehydrated by
the cytosolic enzyme CA- II, to re-form Hþ and HCO-3 , thus
effectively transporting the HCO3- from the tubular lumen into
the cell. The HCO-3 is then reabsorbed in to the systemic cir-
culation along with Naþ ions by the basolateral Naþ-3HCO-3
cotransporter, (NBC1). Thus proximal tubular acidification is
closely linked to Naþ reabsorption. However Naþ reabsorption
in PCT could also be independent of HCO-3 reabsorption, via the
multiple co-transporters that transport Naþ into the cell along
with glucose or phosphate or citrate or amino acids. PCT acid-
ification by HCO-3 reabsorption is influenced by various mech-
anisms. Higher luminal HCO-3 concentration and higher
luminal PCO2 increase proximal Naþ and HCO3- reabsorption,
while increased peritubular HCO-3 concentration reduces it.
Lower extracellular fluid volume, a-adrenergic stimulation &
renin angiotensin aldosterone activation increases NHE3 ac-
tivity and proximal reabsorption. A similar effect is noticed
with glucocorticoids. Higher parathormone (PTH) level in-
creases luminal electro-positivity, stimulating Naþ and HCO3-
reabsorption. Fig. 1 depicts the various mechanisms of prox-
imal acidification in the PCT.
In addition to the bicarbonate reclamation and acid secre-
tion, PCT cell also helps in synthesis and secretion of the
ammonium ðNHþ 4 Þ, which forms the source of ammonia (NH3)
buffer for the distal acidification at the collecting tubule. NHþ
4 is
generated in the PCT by metabolism of glutamine (to gluta-
mate) and is secreted into the tubular lumen by the NHE3, as
the NHþ þ
4 is transported by binding to the H binding site on this
exchanger. Increased ammonium production and secretion
serves to buffer and mop up excessive acid secreted by the
168 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
renal tubules during non-renal systemic metabolic acidosis.
The rate limiting enzymes in the proximal tubular ammonia-
genesis e glutaminase and Phospho-enol pyruvate carboxy
kinase,7 are induced by metabolic acidosis, hypokalemia and
glucocorticoids and inhibited by hyperkalaemia. Despite the
massive bicarbonate reabsorption during the transit in PCT,
the luminal pH changes from an average of 7.4 to 6.74 by the end
of PCT, indicating a negligible net pH change effected by the
acid excretion/bicarbonate reclamation in the PCT.
The loop of Henle contributes by a further 10% bicarbonate
reabsorption, and reabsorption of NHþ 4 (in the thick ascending
limb or TAL) through the Naþ/Kþ/2Cl co-transporter (NKCC2),
by substitution for Kþ on the luminal binding site. The TAL
reabsorption of the NHþ 4 is influenced by the systemic potas-
sium balance and availability of Kþ within the luminal fluid to
inhibit NHþ 4 binding. However, systemic acidosis will enhance
the NHþ þ þ
4 reabsorption. The reabsorbed NH4 loses the H in the
tubular epithelium and diffuses into the interstitium as NH3.
NH3 freely diffuses across the medullary interstitium and with
the help of the counter current multiplication moves into the
collecting tubular lumen. NH3 that enters the collecting tubule
effectively buffers the Hþ ions secreted from the distal nephron,
to from NHþ 4 ions, which gets excreted as such in urine,
contributing to net acid excretion. Increased NHþ 4 excretion is a
major adaptation to acid load. NHþ 4 production and excretion
varies according to physiological needs in keeping with the
considerable flexibility needed to handle the day-to-day varia-
tions in the acid base balance. The net NHþ 4 excretion can in-
crease from a basal normal 30e40 mmol/day up to >300 mmol/
day in conditions of severe systemic metabolic acidosis. Fig. 2
depicts the ammonia generation, reabsorption and secretion.
The distal nephron e collecting ducts have specialized
intercalated cells that take part in acid excretion (uncoupled
from bicarbonate reabsorption), and help in adjusting the net
urine acid excretion to effectively maintain the acid base
Fig. 2 e Ammonia cycle.
balance. The remaining 10e20% of the bicarbonate that enters
the distal nephron is reclaimed with secretion of the Hþ. The
active Hþ secretion is achieved by a-intercalated cells with
their luminal Hþ ATPase and Hþ/Kþ ATPase. The Hþ ATPase is
recruited from the intracellular tubulovesicles, which are used
for the storage of the transporters. The secreted Hþ ions bind
with the remaining HCO-3 ions to form carbonic acid/
H2O þ CO2. Tubular secretion of each mole of Hþ is accom-
panied by intracellular new bicarbonate generation (approxi-
mately 50e100 mmol/day) in the intercalated cell, which is
then reabsorbed into circulation, in exchange to a chloride ion
via the basolateral bicarbonate e chloride exchanger (AE1).
Intracellular chloride concentrations are kept low by the
basolateral chloride channel (ClCKb) and to an extent by the
basolateral Potassium chloride co-transporter (KCC4). The
deficit left by expulsion of the hydrogen ion is addressed by
diffusion of a bicarbonate ion or secretion of a Kþ ion by the
intercalated cell.8 The principal cell, activated by aldosterone,
creates an electrochemical gradient (luminal electronegativity
varying from 5 to 30 mV) favoring acid secretion by the
intercalated cell. In addition, the non-leaky tight junctions
permit steep concentration/pH gradients, allowing acid
secretion to continue. Ammonia that enters the collecting
tubule effectively buffers the secreted Hþ ions to from
ammonium ions, preventing a steep fall in the luminal pH.
Distal acidification is influenced by several factors. Systemic
acidosis increases Hþ secretion, increases ammoniagenesis
and its buffering capacity, thereby facilitating renal acid
excretion. Increased luminal PCO2 reduces distal acid secre-
tion. Increased distal Naþ transport by principal cells, medi-
ated by aldosterone via the ENaC channels create luminal
electronegativity, which increases Hþ secretion. Aldosterone
also increases ammoniagenesis. Hypokalemia not only in-
duces distal Kþ reabsorption and consequent Hþ secretion
(causing alkalosis) but also increases ammoniagenesis.
 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8 169

Apart from ammonia, the phosphate buffers play an
important role. The pK for the equilibrium between H2 PO 4
and HPO2
4 is 6.8. As the urine passes through the collecting
duct where the pH is lower, HPO24 accepts protons and gets
converted to H2 PO
4 thereby buffering excreted acid:
certain extent. However, unlike the NHþ 4 buffer, this capacity is
limited up to a urine pH of 5.5. Fig. 3 represents distal acidifi-
cation mechanism. Defects in acid secretion by intercalated
cell, principal cell mediated electrochemical gradient, and/or
buffering mechanisms cause “distal renal tubular acidosis”.

þ 
HPO2
4 þ H 4H2 PO4

HPO2
4 is major urinary buffer that accounts for buffering 3. Renal tubular acidosis
about 10e40 mEq Hþ/day. This could be easily measured by
amount of NaOH to titrate urine pH (of 24 h urine collection) to 3.1. General considerations
plasma pH (w7.4 normally). Hence, the Hþ thus buffered by
HPO2
4 is called “titrable acid”. As the tubular fluid pH is reduced, The classical review by Rodriguez-Soriano and Edelmann in
the amount of Hþ buffered by phosphate buffer increases to a 19699 defined renal tubular acidosis (RTA) as “a condition in

Fig. 3 e Distal acidification (Panel A e principal cell, Panel B e intercalated cell).

170 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
Table 1 e Etiology of proximal RTA (type II).
1. Isolated defect of proximal acidification
 Primary
- Hereditary
 Autosomal dominant (NHE3) e associated with short
stature and osteomalacia14
 Autosomal recessive (AR) with cerebral calcification and
mental retardation e (CA-II) e CA2 gene on Ch 8q2215
 AR with mental retardation and ocular abnormalities
(NBC-1) e band keratopathy, glaucoma, cataract,
dental defects, pancreatitis and basal ganglia
calcification14,16,17
- Sporadic e Transient infantile pRTA
 Secondary (carbonic anhydrase deficiency) e Acetazolamide,
sulfanilamide, mafenide
2. Fanconi Syndrome e generalized PCT defect e see Fig. 4
which there is a defect in renal excretion of hydrogen ion, or reab-
sorption of bicarbonate, or both, which occurs in the absence of or out
of proportion to an impairment in the glomerular filtration rate”.9
This definition holds good to date. The hallmark of renal
tubular acidosis is the inability to appropriately acidify urine
in the presence of systemic acidosis, despite adequate
glomerular filtration rate. Depending on whether the renal
tubular defect is in distal acid excretion or proximal acidifi-
cation, RTA was classified10 as type I (distal or classic) and type
II (proximal), in chronological order of their descriptions. The
proximal and distal RTA was firmly established by 1969.9 A
third type, type III RTA, was described to display features of
both type I and type II RTA. However, following the description
by McSherry et al, in 1972, where patients who displayed
features consistent with both forms of RTA earlier, evolved
into the classic type I RTA on follow up.11 They were thought
Fig. 4 e Etiology of Fanconi Syndrome. (The common conditions are highlighted in yellow letters) (MLD - metachromatic
Leukodystrophy; HFI - Hereditary Fructose Intolerance, VDDR - Vitamin D dependant Rickets, VDRR - Vitamin D resistant
Rickets, MGUS - Monoclonal gammopathy of undetermined significance, LCDD - light chain deposition disease, PNH -
Paroxysmal nocturnal hemoglobinuria.
to have a reduced renal threshold for bicarbonate reabsorp-
tion with a developmental immaturity of the proximal tubule,
which normalized subsequently. Since then, type III RTA has
been essentially dropped from the classification scheme of
RTA.
Subsequently, patients with aldosterone deficiency were
found to have defective distal acid secretion (resembling distal
RTA) but had hyperkalaemia instead of hypokalemia.12,13 This
form of RTA was then referred to as type IV RTA. Currently,
the diagnosis and classification are made on the basis of
clinical features and biochemical measurements.
3.2. Proximal renal tubular acidosis (Type II)
Proximal RTA is characterized by failure/impairment of prox-
imal acidification, which essentially is due to a reduced HCO3-
reabsorption. The threshold serum concentration for HCO-3
reabsorption is reduced from a mean of 24 mEq/L to 15 mEq/L.
However, distal acidification and ammonia excretion are intact.
The reduced renal threshold for HCO3- is secondary to a defect in
one or more of the following: Hþ ATPase, NHE3, Naþ/Kþ ATPase
or deficiency of CA-IV, or NBC1 or a generalized defect in the
proximal tubular function (Fanconi Syndrome). These defects
could be inherited or acquired. Isolated defects of PCT are rare.
The etiological conditions are given in Table 1 and Fig. 4.
Chromosomal mapping of the inherited (primary) Fanconi
syndrome has now been defined18:
 Autosomal Recessive Fanconi Syndrome e Ch 4q21
(SLC4A4 gene)
 Cystinosis e Ch 2p21/19p13.1 (SLC3A1/SLC7A9 genes)
 Tyrosinemia e Ch 15q23-q25 (FAH gene)
 Galactosemia e Ch 9p13 (GALT gene)
 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
 Dent syndrome e Ch Xp11.22 (CLCN5)
 Wilson DiseaseeCh 13q14.3-q21.1 (ATP7B gene)
Loss of bicarbonate results in systemic metabolic acidosis
with normal anion gap. The proportional loss of bicarbonate
declines as the serum bicarbonate reaches the new threshold
of <15 mmol/L. The bicarbonate that is lost will be accompa-
nied by a mole of cation, to maintain the electroneutrality. The
cation is usually potassium and, to a lesser extent, sodium.
Sodium loss results in volume depletion and polyuria. Hypo-
volemia stimulates renin -angiotensin -aldosterone axis,
initiating angiotensin II mediated preservation of blood pres-
sure and increase in thirst. In addition aldosterone mediated
Naþ reabsorption and Kþ excretion causes blunting of hypo-
volemia and worsening of hypokalemia respectively. Thus,
the clinical manifestations include polyuria, polydipsia, and
hypovolemia with low normal blood pressure and hypokale-
mia with muscle weakness/paresis. The increased distal Naþ
increases distal Ca2þ wasting, resulting in hypercalciuria.
However the increased citrate excretion complexes the cal-
cium and prevent renal calculi or nephrocalcinosis. The
increased loss of bicarbonate causes systemic acidosis, which
is partially mitigated by the intact distal tubular Hþ secretion.
Thus in steady state, on reaching the threshold serum level of
bicarbonate (15 mmol/L), bicarbonate wasting is minimal and
therefore hypovolemia and hypokalemia are rare. However, a
bicarbonate load will precipitate volume loss and hypokale-
mia. In Fanconi Syndrome, the generalized PCT defect, in
addition to bicarbonaturia, there is tubular proteinuria, uri-
cosuria, glycosuria, phosphaturia, citraturia, aminoaciduria,
and refractory vitamin D deficiency state (rickets or osteo-
malacia). Additional clinical features of proximal RTA include
growth retardation, failure to thrive, and bone deformities
(refractory rickets/osteomalacia).
3.3. Distal renal tubular acidosis (dRTA)
Distal RTA is characterized by failure of distal acidification
mechanism. The distal acidification defect due to failure of
distal Hþ secretion (secretory defect) or a secondary defect
with intact secretory mechanism (nonsecretory defect). The
classification of distal RTA is dependant on the cellular
etiopathogenesis:
1. Secretory defect distal RTA: This common variant of distal
RTA is due to an inability to secrete Hþ by the intercalated
cells. The defect is assumed to be in the luminal membrane
Hþ ATPase or Hþ/Kþ ATPase or the AE1 (HCO3- /Cl
exchanger). Secretory dRTA is sometimes known as
“classic dRTA” or rate e limiting dRTA. In this type, the Hþ
secretion is impaired and Kþ is lost instead of Hþ.
2. Gradient defect distal RTA: In this type, the ability to
secrete Hþ is retained, but the gradient is not maintained
due to back-diffusion of the secreted Hþ due to either an
abnormal membrane permeability or loss of properties of
cell junctions. Thus, to compensate for the reversal of Hþ
secretion by back leak, Kþ is lost. This type is also known as
the back leak defect. The prime example is the dRTA
associated with Amphotericin B therapy.19
171
3. Buffer defect distal RTA: There is decreased NH3 delivery to
the distal collecting tubule, resulting in loss of buffering
capacity, steep rise in luminal pH and early loss of gradient.
With less NH3 buffer, secreted Hþ overwhelms the phos-
phate buffer creating an early loss of gradient. This further
impairs Hþ secretion. Due to lack of Hþ secretion in view of
impaired Hþ clearance from lumen, Kþ is lost. This type is
also called the low buffer type dRTA (e.g., Nephrocalci-
nosis, chronic interstitial nephritis)
4. Voltage defect distal RTA: This type results primarily from
principal cell dysfunction, causing a loss of luminal elec-
tronegativity, thereby impairing acid secretion by the
intercalated cell. The principal cell defect is primarily a Naþ
transport defect, characterized either by defective channel
(ENaC), or drugs associated with similar effects (ENaC in-
hibitors). The necessary voltage gradient for Hþ secretion is
not created. Thus Hþ secretion is reduced and Kþ reab-
sorption increases. Thus hyperkalaemia is a common
feature in this type of dRTA. The voltage defect, associated
with hyperkalaemia is often classified as hyperkalemic
type I RTA, is different from the type IV hyperkalemic RTA.
It is commonly seen in conditions such as urinary tract
obstruction, sickle cell disease, salt losing congenital ad-
renal hyperplasia (CAH), and use of Lithium, Amiloride,
Trimethoprim and pentamidine.
Figs. 5 and 6 list the etiological factors of distal RTA.
The inherited forms of distal RTA are often due to the AE1
defect or a defect on Hþ ATPase. Defects of Hþ/Kþ ATPase
have not been well described. Childhood dRTA is often pri-
mary/inherited. The following mutations and phenotypic
patterns have been observed:
1. Autosomal dominant dRTA e AE1 defecteSLC4A1 gene on
Ch 1720 e manifests as dRTA21 with hypokalemia, hyper-
calcemia and nephrocalcinosis, short stature and osteo-
malacia. There is misdirecting of the AE1 channel to the
apical membrane of the a-intercalated cells. It is also
associated with hereditary spherocytosis (HS) and South-
east Asian Ovalocytosis (SAO).
2. Autosomal Recessive dRTA:
a. Hþ ATPase B1 subunit defect22 e ATP6B1 on Ch 2p13 e
typical distal RTA with bilateral sensorineural hearing
loss.23
b. Hþ ATPase A4 subunit defect e ATP6V0A4 on Ch
7q33-3424 e distal RTA with late onset sensorineural
deafness.25
c. AE1 defect e SLC4A1 on Ch 17 e More often in childhood
and in Southeast Asians.
In adults, dRTA is often a complication of systemic lupus
erythematosus or Sjogren syndrome. Sporadic or autosomal
recessive distal RTA manifests with sensorineural deafness
from birth or in late childhood.
Distal RTA results in hyperchloremic non-anion gap meta-
bolic acidosis. As Hþ secretion is impaired the HCO3- reaching
distal nephron is lost in urine. Chronic acidosis results in bone
matrix calcium resorption and progressive osteopenia/osteo-
malacia.26,27 Luminal alkalinization inhibits calcium reab-
sorption resulting in hypercalciuria. Acidosis induced proximal
172 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8

Fig. 5 e Etiology of distal RTA (SNHL - sensory neural hearing loss, Hyper-PTHism - hyperparathyroidism, Hyper-VitD -
hypervitaminosis D, MSK - Medullary sponge kidney, HIVAN - HIV associated Nephropathy, SLE - Systemic lupus
erythematosus, Tx - transplant, NSAID - nonsteroidal anti-inflammatory drugs, Li - Lithium use, IPF -idiopathic pulmonary
fibrosis.

citrate reabsorption causes hypocitraturia.28,29 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. Hypercalcemia with hypocitraturia predisposes to
nephrolithiasis/nephrocalcinosis. Progression of nephrocalci-
nosis may lead to chronic renal failure.
Acidosis induced reduction in proximal fluid reabsorption
and sodium depletion results in polyuria, ECF volume
contraction, RAAS activation, and hyperaldosteronim. The
increased distal delivery and hyperaldosteronism significantly
increased Kþ secretion resulting in hypokalemia. Clinical fea-
tures in distal RTA include polydipsia, polyuria and con-
stipation, impairment of growth, nephrocalcinosis,
nephrolithiasis and hypokalemic muscle weakness or

Fig. 6 e Etiology of voltage defect distal RTA.

 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8 173

paralysis. Growth retardation has been observed in children
with dRTA. In 1981, McSherry and associate11 reported a
blunted growth hormone release in children with RTA. The
pulse amplitude, area, and total growth hormone secretion
were diminished in acidotic rats, while the pulse frequency
remained unaffected in the acidotic animals.30 Distal RTA may
exist in complete and incomplete forms, the incomplete form
being more common.
Incomplete distal RTA: This condition may be much more
common than recognized.31 Characteristic findings include an
absence of systemic acidosis on normal diet, hypercalciuria
with urolithiasis, hypocitraturia, urine containing more NHþ
than expected considering the urine pH, and failure to reduce
urine pH below 5.5 either spontaneously or following an acute
acid load. It was first described in 1959 as a subset of patients
with RTA32 and may represent an early stage of overt dRTA,
characterized by initial increased ammoniagenesis by the
proximal tubule with consequent ability to maintain net acid
excretion.33 Daily net acid excretion is maintained by
enhanced ammoniagenesis.
3.4. Type 4 (hyperkalemic) distal renal tubular acidosis
Type 4 RTA is associated with hyperkalemia due to aldoste-
rone deficiency or resistance to action of aldosterone. This
results in failure of Hþ and Kþ secretion in the collecting duct.
This RTA is characterized also by decreased ammoniagenesis
(1 defect or 2 to hyperkalaemia on PCT), impaired distal
acidification (subnormal NAE and low NHþ 4 excretion) and
hyperkalaemia. However, unlike voltage defect distal RTA
(type 1), the ability to lower urine pH in the presence of sys-
temic acidosis is intact and there is no nephrocalcinosis or
urolithiasis. Type 4 RTA is associated with obstructive urop-
athy. Older children may develop type 4 (RTA) due to
advanced tubulointerstitial renal diseases leading to miner-
alocorticoid resistance, anti-mineralocorticoid drugs, or with
mineralocorticoid deficiency. The various causes are listed in
Fig. 7. Pseudo hypoaldosteronism (PHA) type 1 is characterized
by salt-wasting, 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.
Pseudohypoaldosteronism Type I result from the loss of
function mutations of the aldosterone receptor gene, the MRL
gene. Both autosomal dominant and recessive patterns of
inheritance are observed. The pseudohypoaldosteronism
4 (PHA2) type II or Gordon’s syndrome,34 an autosomal domi-
nant disorder with renal aldosterone resistance presents with
hyperkalemia and hypertension. Mutations in the gene of two
isoforms of WNK serine-threonine kinases, WNK4 and WNK1
genes were identified in patients with PHA2.
Aldosterone increases Naþ absorption creating a negative
intratubular potential facilitating luminal secretion of Kþ. It
induces basolateral Naþ/Kþ/ATPase, causing increased urinary
Kþ losses. Aldosterone deficiency or resistance is expected to
cause hyperkalemia with subsequent inhibition of ammonia-
genesis and acidosis. In type 4 RTA, maximally acidic urine
(<5.5) can be formed, indicating the ability to establish a
maximal Hþ gradient. However, despite the maximally acidic
urine, the rate of ammonium excretion is low.35
4. Laboratory investigations and approach to
diagnosis of RTA
In the traditional approach to diagnosing RTA, the important
pre-requisite for considering the diagnosis is a non-anion gap
metabolic acidosis e otherwise called as hyperchloremic
metabolic acidosis (compensatory increase in chloride). In the
face of non-anion gap metabolic acidosis, measurement of
urine anion gap differentiates the renal and non-renal causes.36

Fig. 7 e Etiology of Type 4 RTA (B/L - bilateral, H’ge - hemorrhage, CA - carcinoma, NSAID - nonsteroidal anti-inflammatory
drug, SLE - systemic lupus erythematosus, ACEi - Angiotensin converting enzyme inhibitor, ARB - angiotensin receptor
blocker, MCKD - medullary cystic kidney disease, CIN - chronic interstitial nephritis, HIV - human immunodeficiency virus
infection).
174 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
Urine Anion Gap (UAG) test is based on the assumption that
metabolic acidosis due to extrarenal HCO-3 losses (diarrhea) is
associated with high urinary NHþ 4 excretion, whereas NH4
þ
excretion is low in patients with RTA. Direct measurement of
Urine NHþ 4 is unreliable and cumbersome, requiring examina-
tion of fresh urine. Thus urine anion gap gives an indirect es-
timate of NHþ þ
4 excretion. The measured urine ions include Na ,
K (cations) and Cl (anion). The unmeasured ions include NHþ
þ 
4 ence of infection with urealytic organisms. However, in many
(cation) and HCO3- , PO3 2
4 , SO4 , organics (anions). Thus,
 þ    
Na Ur þ Kþ Ur þ NHþ4 Ur þ ½minor cations
 
¼ Cl Ur þ ½minor anions
     
UAG ¼ Naþ Ur þ Kþ Ur e Cl Ur
The difference between the anions and cations as given
below is relatively constant at an approximate value of 80.

Naþ þ Kþ þ NHþ4 ¼ Cl þ 80; or


NHþ
4 ¼ 80e Naþ
þ Kþ  Cl
NHþ
4 ¼ 80eUAG
Hence, a urinary anion gap would give an approximate
estimation of ammonium generation in the kidney. Daily
average NHþ 4 excretion is w60 mmol/d. The normal urinary
anion gap is usually positive, and during the conditions of
acidosis with a normal kidney function NHþ 4 excretion in-
crease significantly which would make the urinary anion gap
negative. Thus, UAG value is negative if there is increased NHþ
excretion (gastrointestinal bicarbonate loss, proximal acidifi-
cation defect). In presence of systemic acidosis a positive UAG
indicates inappropriately low renal NHþ 4 excretion as is
exemplified in RTA (distal acidification defect). The interpre-
tation of UAG is valid if urine pH < 6.5. Above this pH, ½HCO-3 Ur
becomes significant and needs to be measured and adjusted
for before interpretation. In addition, interpretation is invalid
in the presence of other unmeasured ions (cations e lithium,
etc., anions e acetylsalicylate, carbenicillin, ketones). In the
presence of the other significant anions the better measure-
ment for differentiating between the renal and non-renal
causes of the normal anion gap metabolic acidosis is the urine
osmolal gap.
Urine Osmolal Gap (UOG) is another alternative indirect
measure of NHþ 4 excretion. The measured urine osmolal sub-
stances are Naþ, Kþ, Urea, Glucose, while the unmeasured
osmolal substances are NHþ 4 , organic acids. Thus, Urine
osmolal gap, the difference between the actual urine osmo-
lality and the calculated urine osmolality by adding up the
measured osmolal units, is given by the formula:
   

UOG ¼ ½OsmUr e 2 Naþ Ur þ 2 Kþ Ur þ ½UreaUr þ ½GluUr
UOG 100 mmol/L, if there is increased NHþ4 excretion. In
general, UOG/2 is approximately equal to ½NHþ4 Ur excretion
(after converting concentration to rate of excretion). However,
interpretation of UOG is invalid in the presence of other sig-
nificant amount of unmeasured osmolals (e.g., lithium). The
next step in evaluation is measurement of urine pH.
Urine pH: Urine pH is to be measured in fresh random early
morning urine sample (collected preferably in a closed
container). Urine pH > 5.5 in the presence of systemic acidosis
indicates a renal acidification defect. Conditions with renal
causes of normal anion gap metabolic acidosis which can
present with urine pH < 5.5 are Type II RTA with low bicar-
bonate load and systemic acidosis and Type IV RTA. Urine pH
has several false positive states, including chronic metabolic
acidosis (increased ammoniagenesis and ammonium excre-
tion), chronic hypokalemia, chronic hypovolemia and pres-
cases of proximal acidification defect, the urine pH may be
<5.5. In incomplete distal RTA, a compensated state reduces
the systemic acidosis and therefore this interpretation may be
impaired. Thus urine pH needs to be interpreted after
inducing systemic acidosis, by acid loading. This can be ach-
ieved by Ammonium chloride loading test (Table 2). Ammo-
nium chloride loading test can cause gastric irritation, nausea,
vomiting. This test should be performed under medical su-
pervision. Ammonium chloride is contraindicated in patients
with chronic liver disease, in whom calcium chloride can be
used as an acidifying agent at a dose of 2 mEq/Kg.
When urine Naþ level is < 5e10 mEq/l, distal Hþ secretion is
low because inadequate negative gradient generation in such
circumstances. Therefore, a high urine pH might not imply a
defect in distal urinary acidification in subjects with low uri-
nary Naþ concentration.
To further characterize the RTA, a sodium bicarbonate
loading test can be performed by either by intravenous or
oral dosing of sodium bicarbonate (Table 2). The secreted Hþ
in the distal tubule reacts with luminal HCO3- to form car-
4 bonic acid, which dehydrates slowly in the medullary col-
lecting duct to form CO2 that is trapped in the renal tubule. In
normal individuals with the serum bicarbonate being in a
steady state at 23e25 mEq/L, alkaline urine (pH > 7.5), the
urine CO2 should be > 70 mm of Hg with a urine-to-blood
PCO2 gradient (U-B PCO2) greater than 20 mm Hg. Similar
values are observed in those with voltage dependent RTA or
aldosterone deficiency (type IV) as the Hþ secretion is well
preserved and increased sodium load negates the voltage
gradient as well as aldosterone deficiency. In classical type 1
RTA with decreased Hþ secretion, a urine PCO2 less than
50 mm Hg and U-B PCO2 <10 mm Hg is seen on bicarbonate
infusion test. In back leak distal RTA the ability to generate
high urinary PCO2 is preserved, because alkaline diuresis
does not favor Hþ back-diffusion. Fractional excretion of bi-
carbonate (FEHCO3) is calculated after adequate alkalization
during the bicarbonate loading test. Fractional excretion <5%
is normal as 90% of bicarbonate is reabsorbed in the proximal
tubule.
urine bicarbonate  plasma creatinine
FEHCO3 ð%Þ ¼  100
plasma bicarbonate  urine creatinine
When the serum bicarbonate is normal (>22 mEq/l), a value
>15% indicates proximal RTA indicating increase renal
wasting of the bicarbonate. Levels <5% are also seen in classic
distal RTA although HCO-3 absorption is incomplete at low
levels of plasma HCO-3 , its absorption increases with
increasing levels. In hyperkalemic distal RTA, the FEHCO3
varies from 5 to 10%.
Despite normal proximal HCO-3 reabsorption, variable de-
gree of fixed bicarbonaturia may occur in type 1 RTA due to the
high urine pH. Thus, even in type 1 RTA with urine pH < 6, the
 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
Table 2 e Ammonium chloride and bicarbonate loading tests.
Ammonium chloride loading test
 Short test
 Oral NH4Cl @ 0.1 g/kg dose
 Hourly ABG and urine pH measured
 Normally e If the plasma total CO2 content falls by 3e5 mEq/L
in view of the acidosis induced hyperventilation, the urine pH
should fall to <5.5
 Urine pH > 5.5 while systemic acidosis / distal acidification
defect
 Prolonged test
 Oral NH4Cl @ 0.1 g/kg dose e divided doses between 12:00 and
21:00 h on 3 successive days
 4th day 7:00 h bladder emptied. 300 ml plan water ingested.
Remain fasting for next 2 h
 8:00 h and 9:00 h ABG and Urine pH and net acid excretion
 Normal response would be an increase by 3e5 times the
baseline urine ammonium by the third day of induced acidosis.
Normally urine pH < 5.5 and NAE 58 mmol/min
FEHCO3 is 3%, while at urine pH > 7 it may exceed 5e10%. It
does not indicate the co-presence of a proximal defect in HCO3-
reabsorption as was proposed for a type III RTA.
The other tests that are helpful in diagnosis of RTA are
given in Table 3.
In addition, other investigations that provide supportive
evidence include, radiological imaging for nephrocalcinosis
Table 3 e Other tests useful in renal tubular acidosis evaluation.
Urine citrate: Citrate is filtered and reabsorbed (PCT) e not secreted.
Source of HCO3- . Excretion is less (or reabsorption increased) with
fall in luminal and PCT cell pH (h systemic pH)
 Normal range ¼ 1.6e4.5 mmol/24 h (adult) or 100 mmol/mmol creat
in spot sample
 Normal in proximal acidification defect (luminal pH is high)
 Reduced in distal acidification defect (luminal and PCT cell pH is low)
Urine calcium: Hypercalciuria is common in distal acidification defect
 24 h urine calcium Normal  4 mg/kg/day
 Spot urine Ca/creat ratio Normal  0.21 mg/mg creat
Tests for phosphaturia
 Tubular reabsorption of phosphate (TRP) is calculated as
Tubular reabsorption [ 100 e fractional excretion
 Fractional excretion of phosphate (FEPO4) is calculated as:
urine phosphate  plasma creatinine
Fractional excretion of phosphate ¼  100
plasma phosphate  urine creatinine
 Normally 5e12% of the ultrafiltered phosphate is excreted and the tubular
reabsorption is 88e95%
 The tubular maximum corrected for GFR (TmP/GFR) is proposed which can be
derived from the Walton Bijvoet normogram37
urine phosphate  plasma creatinine
TmP=GFRðmg=dLÞ ¼ plasma phosphate 
urine creatininesss
 The normal value of TmP/GFR is 2.8e4.4 mg/dL. Older children have lower
values as normal range
175
Bicarbonate loading test
 IV Bicarbonate loading test (takes 3e4 h to achieve target
Se½HCO3-  of 22e26 mEq/L):
 8.4% NaHCO3 as 2 ml/kg bolus followed by 2 ml/min infusion or
 4.2% NaHCO3 infused at 3 ml/min and takes 3e4 h to achieve
steady state
 Oral bicarbonate loading Use of proton pump inhibitors to gastric
distention with CO2. 1 g NaHCO3 ¼ 12 mEq of bicarbonate.
 Full dose: The total dose in mEq required for bicarbonate
loading ¼ (30 e ½HCO-3   Body weight  0:6
 Half dose loading can be performed by administering 2 g
NaHCO3 q15 min
 Urine pH is measured every 30e60 min e Three consecutive
samples with urine pH of 7.5 / termination of the test.
with x-ray and ultrasonography, special urinary tests for an
underlying error of in born metabolism, ocular, otological and
neurological evaluation for associated syndromic clinical fea-
tures. In addition, connective tissue disease work-up and eval-
uation of paraproteinemia are useful. Table 4 shows the
differences in the investigations between the various types of
RTA.
Frusemide test: Frusemide infusion reduces IV
volume / avid PCT Naþ reabsorption with loss of
Naþ reabsorption in TAL, resulting in increased distal
Naþ delivery / avid distal Hþ secretion
 Tab. Fludrocortisone1 mg PO at 22:00 h prev. day þ
overnight fast35
 Morning baseline urine pH and serum electrolytes
 If Urine pH < 5.5 / precludes need for further
testing
 Give Tab. Frusemide 40 mg PO.
 Measure urine pH (& Na, K, Creat) q30 min  5 h
 Normally Urine pH falls to <5.5. Failure to do
so indicates distal acidification defect
 Useful to screen for incomplete distal acidification
defects in the presence of urolithiasis
Transtubular potassium gradient (TTKG):
Estimates action of aldosterone on cortical
collecting tubule
 TTKG ¼ ½Kþ Ur  ½OsmPl O½KþPl  ½OsmUr
 Normal TTKG >4 usually 6e12. With normal
renal responses, TTKG in hypokalemia <2 & in
hyperkalemia >10
 In hyperkalemia if TTKG <8 /
hypoadlosteronism/impaired distal Kþ secretion
176 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8

Table 4 e Differences in evaluation of types of renal tubular acidosis.

Test/Feature Proximal (type II) RTA Distal RTA (type I RTA) Type IV RTA
Hypokalemic Hyperkalemic
During acidosis (or with acid loading)
Urine anion gap Neg Pos Pos Pos
Urine NH4þ excretion N/Y Y Y Y
Serum Kþ N/Y N/Y [ [
Urine calcium N/[ [ [ N/Y
Urine citrate N/[ Y Y N
Urine phosphate [ N N N
With bicarbonate loading (or with normal blood pH)
FEHCO3 >10e15% <5% <5% >5e10%
Ue B PCO2 >20 mm Hg <20 mm Hg >20 mm Hg >20 mm Hg
Other features
Other tubular defects Often present Absent Absent Absent
Nephrolithiasis Absent Present Present Absent
Bone Disease Often present Rare Rare Absent

Fig. 8 provides the algorithmic approach to diagnosis of
RTA and the appropriate use of the detailed investigations
discussed earlier.
5. A brief note on treatment of RTA
Despite advances in diagnosis, therapy of RTA remains mostly
unchanged over the decades. Correction of the systemic
acidosis can restore normal growth in children with dRTA and
decrease the incidence of hypokalemia, nephrocalcinosis/
calculi and CKD progression. However, patients with proximal
RTA, especially children, have comparatively less impressive
improvement, although improvement in skeletal growth and
reduction in the severity of rickets/osteomalacia is noted.
In infant or child with type I or type II RTA and severe,
symptomatic metabolic acidosis (serum HCO-3 less than
12 mEq/L) intravenous bicarbonate should be given for a rapid

Fig. 8 e Algorithmic approach to diagnosis of renal tubular acidosis.

 c l i n i c a l q u e r i e s : n e p h r o l o g y 2 ( 2 0 1 3 ) 1 6 6 e1 7 8
correction, at appropriate dose required to achieve a desired
change in serum bicarbonate.38
Dose required ¼ desired change in serum bicarbonate
 body weight in kg  0:6:
This formula assumes a bicarbonate distribution space of
60% kg body weight. Half of the dose calculated should be
given over first 8 h and the rest in the subsequent 24 h.
However, in patients with moderate metabolic acidosis with
serum bicarbonate concentrations of more than 12 and less
than 17 mEq/L, instead of intravenous therapy, oral bicar-
bonate therapy will suffice. Thiazide diuretics and low sodium
diet are employed to decrease bicarbonate wasting and
thereby reduce the bicarbonate requirement to maintain the
blood pH and consequently reduce the requirement of po-
tassium supplements for hypokalemia. There are various
combination formulations available. Shohl’s solution (or
Bicitra), which contains citric acid and sodium citrate is more
palatable than sodium bicarbonate, providing 1 mEq/ml of
base.39,40 Polycitra K solution contains potassium citrate to
provide 2 mEq/ml of alkali and 2 mEq/ml of potassium,
designed to correct both acidosis and hypokalemia.39,40
The therapeutic goal in distal (Type I) RTA is to achieve a
relatively normal serum bicarbonate concentration
(22e24 meq/L). The specific dose and agent of choice varies
with patient’s age. Adults require 1e2 meq/kg of sodium bi-
carbonate or sodium citrate (ie, Bicitra); while children are
treated with much larger doses of alkali (4e8 meq/kg per day in
divided doses41) as bicarbonate losses are higher in view of the
acid load from growing skeleton. Alkalinizing potassium salts,
such as potassium citrate, alone or with sodium citrate (Poly-
citra), are useful in hypokalemic RTA. A larger dose of Shohl’s
solution/Polycitra is advised at bedtime in type I RTA based on
the rationale that growth hormone secretion is maximal dur-
ing sleep and that the optimal correction of metabolic acidosis
during this period will have a significant beneficial effect on
growth.40 Thiazide diuretic use in type I RTA may cause mild
volume depletion and proximal bicarbonate reabsorption and
more importantly decrease the hypercalciuria.
Treatment of proximal (Type II) RTA is difficult, as bicar-
bonate loading is associated with increased bicarbonaturia,
polyuria, and hypokalemia. Thus, type II RTA requires higher
and more frequent doses of Bicitra, as high as 14 mEq/kg per
day, because of the large proximal tubular loss of bicarbonate.
Hypokalemia due to increased potassium wasting occurs as a
consequence of increased sodium load with treatment and a
consequent increase in the daily potassium requirement with
correction of acidosis in type II RTA.42 Thiazide use is benefi-
cial as it induces mild volume depletion that reduces urinary
bicarbonate loss by enhancing the proximal reabsorption of
sodium and secondarily that of bicarbonate. Renal phosphate
wasting in type II RTA secondary to Fanconi syndrome needs
careful phosphate replacement.
Treatment of type IV RTA Patients with congenital adrenal
hyperplasia require replacement treatment with flu-
drocortisone 0.1e0.3 mg/d (0.05e0.15 mg/m2 per day).39,40
Loop diuretic in isolation or in combination with the thia-
zide diuretics may be needed to increase potassium excretion.
Potassium restriction in diet and oral administration of
177
potassium binders may be necessary. To compensate for the
metabolic acidosis, bicarbonate of 1.5e2.0 mEq/kg per day is to
be supplemented.
6. Conclusion
Renal tubular acid excretion exemplifies the complex inter-
action of various systemic and tubular players in carefully co-
ordinating and maintaining the body’s acid base balance in a
precise manner. Renal tubular acidoses due to proximal and
distal acidification defects have varying etiological, patho-
physiological, and phenotypic features. A clear understanding
of the normal physiology and the pathophysiological changes
in these disease states is very rewarding, not only satisfying
the academic interest, but also carrying several important
clinical and therapeutic implications. Although they appear
complex to diagnose to the untrained eye, once the basic
principles are clarified, they become simple disorders that are
logical to diagnose and easy to treat.
Conflicts of interest
All authors have none to declare.
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