CLINICAL CORRELATION IN BIOCHEMISTRY

INTRODUCTION TO
ACIDOSIS AND ALKALOSIS

Clinical Case (Introduction)

• Ms X (“diabetes”) is a 26-year-old woman who was diagnosed with
type 1 diabetes mellitus at the age of 12. She has an absolute insulin
deficiency resulting from autoimmune destruction of the β-cells of her
pancreas. As a result, she depends on daily injections of insulin to
prevent severe elevations of glucose and ketone bodies in her blood.
When Ms. X could not be aroused from an afternoon nap, her
roommate called an ambulance, and she was brought to the
emergency room of the hospital in a coma. Her roommate reported
that X had been feeling nauseated and drowsy and had been
vomiting for 24 hours. Ms. X is clinically dehydrated and her blood
pressure is low. Her respirations are deep and rapid, and her pulse
rate is rapid. Her breath has the “fruity” odor of acetone.
Blood samples are drawn for measurement of her arterial blood pH,
arterial partial pressure of carbon dioxide (PaCO2), serum
glucose, and serum bicarbonate (HCO3-). In addition, serum and
urine are tested for the presence of ketone bodies and Ms. X is
treated with intravenous normal saline and insulin. The lab reports
that her blood pH is 7.08 (reference range 7.36-7.44) and that ketone
bodies are present in both blood and urine. Her blood glucose level is
648 mg/dL (reference range = 80-110 after an overnight fast, and no
higher than 200 in a casual glucose sample taken without regard 2 to
the time of a last meal).

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 Prerequisite
You should know & you are responsible of:

• Covalent & non-covalent bonds

• Special properties of water

OBJECTIVES:

Upon completion of lecture students should be able to:

• Understand pH, pKa and buffers

• State major buffers that regulate blood pH

• Use Henderson-Hasselbalch equation to

describe pH changes as a result of changes in
HCO3- and pCO2

• List factors that determine blood pH and

describe how they do so 4

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 OBJECTIVES (cont.):

Upon completion of lecture students should be able to:

• Describe respiratory acidosis and alkalosis

• Describe metabolic acidosis and alkalosis

• Give clinical examples of respiratory acidosis

and alkalosis

• Give clinical examples of metabolic acidosis

and alkalosis
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Basic concepts and definitions: pH review

pH = -log [H+]
H+
• Pure water is slightly ionised. H+
H+
H 2O H+ + OH- H+ H+
(Acidic) (Basic)

• The concentration of H+ ions in water is defined by the pH

• Small “p” means – log
• Therefore pH means – log [H+] where [H+]is expressed as
Molar (moles/liter).
• Thus pH of 7.0 = 10-7 M H+ or 100 nM H+
• pH of 8.0 = 10-8 M H+ or 10 nM H+
• Normal blood pH is 7.4 = 10-7.4 M or 40 nM H+
• pH extremes of 6.8 and 7.8 will lead to death 6

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Basic concepts and definitions: pH Scale
• H2O H+ + OH-
• Keq = [H+] [OH-]
[H2O]
• [H ] [OH-] = Keq x [H2O]
+

(1.8 x 10-16) x 55.5

= 10-14 M2 = Kw

• Neutral pH is the pH at which [H+] = [OH-]

• [H+] [OH-] = 10-14 [H+] = [OH-] = 10-7

• Neutral pH = 7
• Physiological pH = 7.4

• The ion product of water is the basis for the pH scale where
values of 0 to 14 indicate the concentration of [H+]. 7

Basic concepts and definitions: Properties

of weak acids and bases
Acid: chemical species that can donate a proton (H+) in
an aqueous solution

Base: chemical species that can accept (gain) a proton

conjugate
acid base
H+
HA H+ + A-
HA H+ A-
HA H+ A-

conjugate
acid acid
HA + H2O H3 O + + A -
base conjugate
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base

4
 Basic concepts and definitions: pKa

• A weak acid has a tendency to lose a proton

HA A- + H+

• The equilibrium constant of this reaction is:

[H+][A-]
Keq = [HA] = Ka (the dissociation constant)

pKa = -logKa

Note: The greater the tendency to lose the H+, the

larger the dissociation constant.
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What does pKa mean?

HENDERSON-HASSELBACH EQUATION
Ka = [H+][A-]
[HA]
+ +
Solve for [H ]: [H ] = Ka [HA]
[A-]
Take negative logs: -log [H+] = -log Ka - log [HA]
[A-]
pH = pKa - log [HA] • The Henderson-Hasselbach equation
[A-] relates the pH of an acid to its pK.
• This equation is very important in
If [HA] = [A-] clinical medicine
pH = pKa -log 1.0
pH = pKa

So, pKa is the pH at which half of the acid is ionised.

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5
 Buffering/Titration

At pH 3.76,
10% is ionised

At pH 4.76,
50% is ionised

At pH 5.76,
90% is ionised

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Acid-Base Buffers
• Acid-base buffer: a solution whose pH resists change upon
addition of either more acid or more base
– consists of a weak acid and its conjugate base
• Examples of acid-base buffers are solutions containing
– CH3COOH and CH3COONa
– H2CO3 and NaHCO3
– NaH2PO4 and Na2HPO4

Buffer Capacity
• Buffer capacity is related to the concentrations of the
weak acid and its conjugate base
– the greater the concentration of the weak acid and its
conjugate base, the greater the buffer capacity 12

6
 Selecting a Buffer

• The following criteria are typical

– suitable pKa
– no interference with the reaction or detection of
the assay
– suitable ionic strength
– suitable solubility
– its non-biological nature

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Buffers in the Body

• H2PO4-/HPO42- is the principal buffer in cells
• H2CO3/HCO3- is an important (but not the only) buffer in
blood
C O 2( g) CO 2( aq )

CO 2( aq ) + H 2 O(l) H 2 C O 3 (a q)

H 2 CO 3 (a q) H + (a q) + HCO 3 - (a q)

C O 2( g) + H 2 O(l) H + (a q) + HC O 3 - (a q)
– hyperventilation can result in increased blood pH
– hypoventilation can result in decreased blood pH
– Carbonic anhydrase catalyses the reaction:
CO2 + H2O H2CO3
– Possible to adjust blood pH by altering concentration of
dissolved CO2.
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– To lower CO2, breathe more rapidly.

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 Henderson-Hasselbalch equation
in practice
• A patient with uncontrolled diabetes has a low blood pH, due
to the accumulation of compounds called ketone bodies, that
are acidic. To try to compensate for this a diabetic patient will
change his/her breathing rate.

• Use the Henderson-Hasselbalch equation to determine

whether such a patient is likely to breathe more rapidly or
more slowly.

• Acidosis is often treated by giving patients bicarbonate

(HCO3-) to raise blood pH.

• Clinicians use the HH equation to calculate how much HCO3-

to give a patient with acidosis to raise pH to 7.4
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Clinical Correlation: Blood Bicarbonate

Concentration in Metabolic Acidosis
• Blood values of a patient with metabolic acidosis : pH = 7.03, and
[CO2] = 1.10 mM. What is the patient’s blood [HCO3-], and how much
of the normal [HCO3-] has been used in buffering the acid causing the
condition?
• In acidosis, it is important to monitor the acid-base parameters of
patient’s blood. Values (normal) of interest to a clinician:
pH 7.4, [HCO3-] = 24.0 mM, [CO2] = 1.20 mM
• 1. The Henderson-Hasselbalch equation:
pH=pK’+ log ([HCO3-]/[CO2]) (pK’ for ([HCO3-]/[CO2]) is 6.10
• 2. substitution: 7.03=6.10 + log ([HCO3-]/1.10)
7.03-6.1=0.93=log ([HCO3-]/1.10)
Antilog of 0.93 is 8.5 = [HCO3-]/1.10
[HCO3-] = 9.4 mM
• Since the normal value of [HCO3-] = 24 mM, there has been a decrease
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of 14.6 mmol of HCO3- per liter of blood in this patient.

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 Basic concepts and definitions:
” -EMIA”: describes a condition of the blood
For describing blood pH problems we say:

• Acidemia: pH < 7.35

• Alkalemia: pH >7.45
Normal blood pH range is 7.35-7.45
pH limits of 6.8 or 7.8 are incompatible with life
” -OSIS”: Describes a process

• Acidosis: Process producing acidemia (pH<7.35)

Either an excessive amount of acid or a decrease in alkaline
substances is the cause

• Alkalosis: Process producing alkalemia (pH>7.45)

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Either too many alkaline substances or not enough acid substances.

• The most important way that the pH of the blood is kept relatively
constant is by buffers dissolved in the blood.

• Other organs help enhance the homeostatic function of the buffers.

The Carbonic-Acid-Bicarbonate Buffer in the Blood

Most important buffer for maintaining acid-base balance in the blood. The
simultaneous equilibrium reactions of interest are:

H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO2(g)

We are interested in the change in the pH of the blood; therefore, we want an

expression for the concentration of H+ in terms of an equilibrium constant and
the concentrations of the other species in the reaction (HCO3-, H2CO3 and
CO2).

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9
The Carbonic-Acid-Bicarbonate Buffer in the Blood

acid-base reaction
K1 K2
H3O+(aq) + HCO3- (aq) H2CO3 (aq)+ H2O(l) 2 H2O(l) +
CO2(g)
not an acid-base reaction

H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO2(g)

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H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO2(g)

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 Open System Closed
Concept
CO2=11.2

HCO3- = 14
pH = 6.20

+ 10 CO2 lost
+ 10 H+
CO2 = 1.2

HCO3- = 24
pH = 7.40
CO2 = 1.2 CO2 = 0.9

HCO3- = 14 HCO3- = 14

pH = 7.17 pH = 7.29

Open Compensated
H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO212(g)

• The most important way that the pH of the blood is kept relatively
constant is by buffers dissolved in the blood.

• Other organs help enhance the homeostatic function of the buffers.

• The kidneys help remove excess chemicals from the blood.

It is the kidneys that ultimately remove (from the body) H+ ions and other
components of the pH buffers that build up in excess. Acidosis that results
from failure of the kidneys to perform this excretory function is known as
metabolic acidosis. However, excretion by the kidneys is a relatively slow
process, and may take too long to prevent acute acidosis resulting from a
sudden decrease in pH (e.g., during exercise).

• The lungs provide a faster way to help control the pH of the blood.
The increased-breathing response to exercise helps to counteract the pH-
lowering effects of exercise by removing CO2, a component of the principal
pH buffer in the blood. Acidosis that results from failure of the lungs to
eliminate CO2 as fast as it is produced is known as respiratory acidosis.
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Lung and kidney help enhance the homeostatic
function of the buffers.

CO2

[Kidney] (slow)
pH ~
~ [Lung] (fast)
HCO3- + H+

HCO3- H+ : Phosphoric
acid, NH4+
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H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO2(g)

Time course of distribution, buffering, respiratory

compensation and renal excretion of an acid load
H+
Distribution
Load and extra-
Cellular Cell
buffering buffering
100
Respiratory
Renal H+
compensation
secretion

50

0 6 12 24 72
Hours 24

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 Gastrointestinal losses can create acid-base
disturbances
Vomiting:
Loss of H+
leading to
alkalosis
Highly acidic, pH =1.0

Secretes HCO3-

Diarrhea:
pH varies from
Loss of HCO3- 4.0 to 8.0
leading to
acidosis

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Causes of acid-base imbalances

Metabolic acidosis Metabolic alkalosis
Diabetic ketoacidosis Shock Loss of gastric secretions
Diarrhea Salicylate overdose Overuse of antacids
Renal failure Sepsis Potassium-wasting diuretics

Respiratory acidosis Respiratory alkalosis

Hypoventilation, possibly related to: Hyperventilation, possibly related to:

Drug overdose Airway obstruction Anxiety Hypoxia

Chest trauma COPD High altitude Excessive ventilator
Pulmonary edema Neuromuscular assistance
disease Pregnancy
Fever Initial stage of
pulmonary embolus

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 To diagnose an acid-base imbalance, ask 3 questions:
•Does the pH indicate acidosis or
alkalosis?
•Is the cause of the pH imbalance
respiratory or metabolic? CO2
•Is there compensation for the acid-
base imbalance?

ACID-BASE Parameters

HCO3- + H+

H+
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HCO3-

Diagnosing acute Acid-base disorders

60-year-old diabetic with a long history of not taking her insulin.
She is admitted to the hospital and you receive the following
data on her: pH 7.26, PaCO2 42, HCO3- 17
ACID-BASE Parameters

Acid Normal Alkaline

pH PaCO2
HCO3 -

• If the pH and PaCO2 fall in the same column - other than

normal, of course - the problem is respiratory.

• If the pH and HCO3- fall in the same column, the problem28is

metabolic. Thus, the diagnosis is metabolic acidosis.

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A 1st year medical student was anxious about her performance on the 1st
biochemistry test. She felt numbness around her mouth and tingling in her
hands and went to the clinic. A workup revealed: pH 7.48, PaCO2 30, HCO3- 23

I knew I should
have studied
my
Biochemistry
notes….
ACID-BASE Parameters

Acid Normal Alkaline

pH
HCO3 - PaCO2 29

H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO2(g)

pH pH
7.48 7.4

CO2

30

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A 1st year medical student who did really well on his 1st biochemistry test
celebrated too much afterwards. After a weekend of atonement, his lab values
are: pH 7.48, PaCO2 51, HCO3- 29

ACID-BASE Parameters

Acid Normal Alkaline

PaCO2 pH
HCO3-

Metabolic alkalosis with

Partial respiratory compensation.

H+(aq) + HCO3- (aq) H2CO3 (aq) H2O(l) + CO

31 2(g)

Deciphering Compensated Cases

If pH is within the normal range but the other parameters

are not, it is a case of complete compensation.

An additional step is then needed to diagnose the origin of the imbalance.

• Record the pH in the normal range. Then examine pH

using the exact midpoint of the normal range, or 7.40.

• pH of less than 7.40 would indicate acidosis, and one greater

than 7.40 would be alkalosis. Draw an arrow towards the
Appropriate column.

32

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 45 yo man with pneumonia. Admitted for evaluation and complaining
of progressive difficulty breathing. His acid-base data are:
pH 7.36, PaCO2 50, HCO3- 34

ACID-BASE Parameters

(7.4)
Acid Normal Alkaline

pH
PaCO2 HCO3-
The diagnosis is now clear: respiratory acidosis with complete compensation.
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A 50-year-old executive complains of indigestion and heartburn that have

increased over the last six months. He took a commercial antacid solution
every half hour or so throughout the previous night for symptom relief.
His pH is 7.43, PaCO2 is 49, and HCO3- is 30.

ACID-BASE Parameters

(7.4)
Acid Normal Alkaline

pH
PaCO2 HCO3-

pH is normal while the other parameters are not. Therefore, complete compensation.
Adjusted pH is alkaline and falls into the same column as HCO3- so the full diagnosis
is metabolic alkalosis with complete compensation. Because of his increased alkali
intake, his respiratory system normalized the pH by retaining CO2. 34

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