Laura Fox

Grandma’s TUM-my Trouble: A Case Study in Renal Physiology and Acid-Base

Balance
Part I
1. Are any of the lab values in Table 1 out of normal range? Do you see some
that are too high or too low?
Pretty much all of them are out of normal range. The serum
creatine levels were far too high– 8.3 mg/dL (.5-1.4 mg/dL regular).
The BUN (blood urea nitrogen) levels are very high, 55 mg/dL instead
of 6-22 mg/dL. Serum Calcium levels are much too high (15.76…max
should be around 10). Sodium (Na) levels were far too low (128,
should be at least 135). Serum pH is way too high– 7.67 instead of
7.35-7.45. Urinary Potassium was way too high– 45 instead of 3.5-5.2.
2. Which of the lab values gives you information about how Mrs. Burroughs’
kidneys are functioning?
The BUN and Serum Creatine.
3. Does Mrs. Burroughs have acidosis or alkalosis? Why do you think this?
Alkalosis (her blood is baser than normal).  Able to tell because
her blood pH was 7.67, which is more basic than average blood.
4. Why is the physician interested in Mrs. Burroughs’ kidney function?
The symptoms that Mrs. Burroughs’ son described to the
doctor all relate to the kidney function, therefore a kidney check up is
necessary to find out if her symptoms are indeed due to some kidney
malfunction or because of something else.
5. What else do you think you will need to know about Mrs. Burroughs? How
could you get this information?
We should know her medical history, to start off. We need to
know if she is taking any medications that might affect her
kidneys/not mix together. Digestive tests would give useful
information about the state of her gut and whether or not her kidneys
are working correctly. Hormone levels could be tested to determine if
there are any unusual amounts floating around in her bloodstream,
which might cause the lethargy and disorientation. It would probably
be good to check the brain (and possibly the whole body) using an
MRI to determine if stroke could be a possible cause or if any other
brain malfunctions have occurred.

Part II
1. Should you and the family be concerned about anything that Mrs. Burroughs
takes that is not a prescription medicine? Why or why not?
Yes, because it changes the body’s chemistry and will affect the
other medications, either on a small or large scale.  These other non-
prescription drugs can either limit a medication’s success or counter it
or cause it to do something that it’s not supposed to do.
 2. Could any of Mrs. Burroughs’ current problems be related to the drugs (over-
the-counter or prescription) she has been taking? Describe why you think
there is a relationship.
First, the prescription drugs by themselves would not be the
ones to cause her this health problems due to the way they were
prescribed, her doctor was most likely aware of the possible side
effects that she would experience. Now to the over-the-counter
medication, the fact that she took this medication more than she
needed might have affected her. Also the mix between the two types
of medication would have taken a toll on her health.
3. What is parathyroid hormone (PTH)? Where does it come from and what is
its function?
Parathyroid hormone destroys osteoclasts to put more calcium
in the blood. (Having too little calcium in the blood causes the nerves
to overreact and become ‘tingly’). Parathyroid hormone is produced
by the Parathyroid, which is located in the throat near the Thyroid
glands.
4. Why do you think the physician wants to know about the levels of this
hormone?
The patient has high levels of serum calcium in the blood,
which is an implication of hyperparathyroidism.
5. What are normal levels for PTH?
Normal levels of PTH are within the ranks of 150-300 pg/ml.

Part III
1. What enzyme catalyzes the formation of H2CO3 from CO2 and H2O? (This
enzyme also catalyzes the formation of H2O and CO2 from H2CO3.)
The enzyme is called carbonic anhydrase.  This enzyme
contains zinc, and is used in a variety of body parts, especially the
transport/exchange of CO2 from red blood cells to alveoli in lungs. A
carbonic anhydrase II deficiency causes acidosis
2. The diagram above (Figure 1) outlines the mechanism by which H+ is
actively secreted into the PCT of the kidney nephron. What other substances
must be transported from the tubular fluid into the PCT cell (across the
apical or luminal membrane) or from the PCT cell into the interstitial fluid
(across the basolateral membrane) as part of the transport of the H+ ?
The substances that are secreted into the tubular fluid (for
removal from the body) include:Potassium ions (K+), Hydrogen ions
(H+), Ammonium ions (NH4+), Creatinine, Urea, Hormones, Drugs
(e.g. penicillin). Helps to keep blood pH at its normal level. The
movement of these ions also helps to conserve sodium bicarbonate
(NaHCO3).
3. What would happen to the amount of H+ secreted into the renal tubule if the
activity of the Na+/K+ ATPase were increased? Are there diseases or other
conditions that might enhance the activity of this sodium pump?
ATPase pumps on basolateral membrane pumps Na out of the
 luminal. Potassium is transported into tubular cells by basolateral Na
pumps, therefore if the amount of Na increases, the ATPase will have
trouble pumping correctly all of this, leading to a problem in the
kidneys and the urination flow. Now it is absolutely clear that a lot of
Mrs. Burroughs’ problems were caused by the medications she was
taking and their interactions with her kidneys.

Part IV
1. Is there a problem with Mrs. Burroughs’ breathing? What kind of change (if
any) do you expect to see in the respirations of a person with metabolic
alkalosis?
There is no problem with Mrs. breathing, but since she has
metabolic alkalosis, slow breathing may be the first symptom, and
later she may experience apnea that may last 15 seconds or longer.
Cyanosis, a bluish purple discoloration of the skin, might show a lack
of oxygen intake.
2. Can you draw a diagram that shows how the respiratory system, under the
control of the central nervous system, responds to alkalosis

Arterial Blood
Sample

pH?

< 7.4 > 7.4

Acidosis Alkalosis

HCO3 < 24 Pco2 >40 mm HCO3 >24 Pco2 <40 mm

mEq/L Hg mEq/L Hg

Metabolic Respiratory Metabolic Respiratory

Respiratory Renal Respiratory Renal

Compensation Compensation Compensation Compensation
3. Why do you think the physician suspected PTH levels that are too low?
PTH controls calcium and phosphorus levels in the blood. If the
blood calcium level is too low, the parathyroid glands release more
PTH. Grandma was taking thiazide diuretic which causes a decline on
how the DTC absorbs sodium and chloride from the tubular fluid.  She
was taking way too much calcium by drinking large amounts of milk
and some calcium from the Tums.
4. Describe how the thiazide diuretics (like the hydrochlorothiazide that Mrs.
Burroughs takes) can produce or contribute to alkalosis and hypercalcemia.
Thiazide diuretics can contribute to hypercalcemia by inducing
the distal tubule (in the kidneys) to increase the amount of calcium
that is reabsorbed into the body.  It contributes to alkalosis by
increasing the amount of Potassium (K) that replaces the Hydrogen
(H), which makes the blood pH more base.