Acid base disorder

Tim dosen patologi

 The concept of acid base balance
Acid-base balance refers to the mechanisms
the body uses to keep its fluids close to neutral
pH (that is, neither basic nor acidic) so that the
body can function normally.
Arterial blood pH is normally closely
regulated to between 7.35 and 7.45.
 Any ionic or molecular
Any ionic or molecular
substance that can act as a
substance that can act as a
proton acceptor.
proton donor.
Strong alkali：NaOH, KOH.
Strong acid：HCl, H2SO4, H3PO4.
Weak alkali ： NaHCO3, NH3,
Weak acid：H2CO3, CH3COOH.
CH3COONa.

acids?? bases??
 Origin of acids Much more
 Intracellular metabolism
Volatile CO2+H2O=H2CO3 300~400L CO2 (15mol H+)
acids

Lactic acid
Ketone bodies
Fixed 50~100 mmol H+
Sulfuric acid
acids
Phosphoric acid

Origin of bases less  NH3 , sodium citrate, sodium lactate

ACID BASE BALANCE AND
REGULATION
 pH
 pH of ECF is between 7.35 and 7.45.
Deviations, outside this range affect
membrane function, alter protein function,
etc.
 You cannot survive with a pH <6.8 or >7.7
 Acidosis- below 7.35
 Alkalosis- above 7.45

 CNS function deteriorates, coma, cardiac

irregularities, heart failure, peripheral
vasodilation, drop in BP.
 Given that normal body pH is slightly alkaline and that
normal metabolism produces acidic waste products
such as carbonic acid (carbon dioxide reacted with
water) and lactic acid, body pH is constantly
threatened with shifts toward acidity.
 In normal individuals, pH is controlled by two major
and related processes  pH regulation and pH
compensation.
 Regulation is a function of the buffer systems of the
body in combination with the respiratory and renal
systems, whereas compensation requires further
intervention of the respiratory and/or renal systems to
restore normalcy.
buffering？

HA H+ + A

[ H+ ]  [ A ]
Ka =
[ HA ]

[ HA ]
[ H+ ] = Ka 

[A ]
[ A ]
pH = pKa + lg
[ HA ]
 • by the body fluids that immediately combine with acids
ACID-BASE or base to prevent excessive changes in pH
BUFFERING

• which regulates the removal of volatile CO2 as a gas in

the expired air from the plasma and therefore also
regulates bicarbonate (HCO3-) from the body fluids via
RESPIRATORY the pulmonary circulation.

• which can excrete either acid or alkaline urine, thereby

adjusting the pH of the blood.
KIDNEYS
 H＋ load

ECF Lung ICF Renal Bone

Buffers RBC Respiratoryc H＋ －K＋ H+ excretion Release

ontrol exchange bicarbonate bone salt
Hb others reabsorption
buffers
H2CO3 CO2
Buffers Ca2＋ ＋H2PO4
Acid In chronic
excretion metabolic
Expiration acidosis

Immediately minutes hours days Very slow

Buffers system extracellular
Renal control of acid-base balance
• The kidneys control acid-base balance by excreting
either an acidic or basic urine.
– The kidney filters large volumes of HCO3- and the extent to
which they are either excreted or reabsorbed determines
the removal of “base” from the blood.
– The kidney secretes large numbers of H+ into the tubule
lumen, thus removing H+ from the blood.
• The “gain” of the adjustment of pH by the kidney and
the acid base balance it regulates is nearly infinite,
which means that while it works relatively slowly, it can
COMPLETELY correct for abnormalities in pH.
• The kidneys regulate extracellular fluid pH by secreting H +,
reabsorbing HCO3-, and producing new HCO3-
• During alkalosis, excess HCO3- is not bound by H+, and is
excreted, effectively increasing H + in the circulation and
reversing the alkalosis.
• In acidosis, the kidneys reabsorb all the HCO 3- and produce
additional HCO3-, which is all added back to the circulation
to reverse the acidosis.
• H+ is secreted and HCO3- reabsorbed in all segments of the
kidney except for the thin limbs of the loop of Henle.
(however, HCO3- is not readily permeable through the
luminal membrane).
 Primary
changing

CO2 CO2 + H2O

CA
plasma H2CO3 RBC
CA
 
HCO3 HCO3 H+

C l C l
Hb buffering
Cl¯ transfer

CA ： carbonic anhydrase
The compensation effect of RBC
uBuffers only provide a temporary
solution.
uLung: responds rapidly to altered
plasma H+ concentrations, and keep
blood levels under control until the
kidneys eliminate the imbalance.
uKidney:are the ultimate H+ ions balance.
Slow acting mechanisms can eliminate
any imbalance in H+ levels.
ACID BASE DISTURBANCE
 Definition of acid-base disorders

 An acid base disorder is a change in the normal

value of extracellular pH
 When is it happen??
 renal or respiratory function is abnormal
 an acid or base load overwhelms excretory capacity
 Simple acid – base disorders
• Clinical disturbances of acid base metabolism
classically are defined in terms of the
HCO3¯ /CO2 buffer system.
• Acidosis : process that increases [H+]
– increasing PCO2 or by reducing [HCO3-]
• Alkalosis : process that reduces [H+]
– reducing PCO2 or by increasing [HCO3-]
 Since PCO2 is regulated by respiration,
abnormalities that primarily alter the PCO2
are referred to as respiratory acidosis (high
PCO2) and respiratory alkalosis (low PCO2).
 In contrast, [HCO3¯] is regulated primarily by
renal processes. Abnormalities that primarily
alter the [HCO3¯] are referred to as metabolic
acidosis (low [HCO3¯]) and metabolic
alkalosis (high [HCO3¯]).
 PaCO2
(Partial Pressure of Carbon Dioxide)

The amount of carbon dioxide dissolved in arterial blood.

 Normal: 4.39 ～ 6.25kPa（35 ～ 45 mmHg）
 Average: 5.32 kPa（40 mmHg）
 Respiratory acidosis: > 45 mmHg
 Respiratory alkalosis: <35 mmHg
The PaCO2 reflects the exchange of this gas through the lungs
to the outside, so it is called “respiratory parameter”.
 HCO3-

• Normal: 21～ 26 mmHg）

• Average: （24 mmHg）
• Metabolic acidosis: < 21 mmHg
• Metabolic alkalosis: > 26 mmHg
 pH
pH is a measurement of the acidity of the blood, reflecting
the number of hydrogen ions present.
pH = - log [H+]
pH7.45：alkalosis
pH7.35：acidosis
pH 7.35 - 7.45：
①Acid-base balance.
②Acidosis or alkalosis with complete compensation.
③A mixed acidosis and alkalosis, both events have opposite
effects on pH, may also have a normal pH.
 Step
assessment of the arterial blood gas
profile >> penilaian pH analisis
kasus

appraisal of the pCO2 and [HCO3-] to

identify the primary derangement
and compensatory response

assessing the adequacy of the

compensatory response by applying
the rules of compensation

examine the serum electrolytes and

anion gap (AG) and to decide
whether additional testing is required
 Compensation
• The body response to acid-base imbalance is called
compensation
• Complete  if brought back within normal limits
• Partial compensation  if range is still outside norms.

• If underlying problem is metabolic, hyperventilation or

hypoventilation can help respiratory compensation.
• If problem is respiratory, renal mechanisms can bring
about metabolic compensation.
 Asidosis

pCO2 ↑ HCO3 ↓

HCO3??
PCO2??
N : belum terjadi kompensasi
N : belum terjadi kompensasi
↑ : kompensasi renal (parsial)
↓ : kompensasi paru (parsial)
↓ : mixed (respiratory &
metabolic disorder) ↑ : mixed disorder
 Alkalosis

pCO2 ↓ HCO3 ↑

HCO3??
PCO2??
N : belum terjadi kompensasi
N : belum terjadi kompensasi
↑ : mixed (respiratory &
metabolic disorder) ↓ : mixed disorder
↓ : kompensasi renal (parsial) ↑ : kompensasi paru (parsial)
 Metabolic Primary [HCO3]
AG : anion gap

acidosis

Increased AG
Lactic acidosis
generate
Source ketoacidosis
Acids Fixed acids Salicylic acidosis intake

Exclusion ：renal failure

Source   —— impossible

Normal AG
From GI：diarrhea
Bases Loss 
From kidney：proximal/distal tubular acidosis

Consume  ：ammonium chloride have been administered

 Metabolic Acidosis occurs when the kidneys fail to excrete
acids formed in the body, or there is excess ingestion of acids,
or the loss of bases from the body
• Renal Tubular Acidosis: due to a defect in H+ secretion or
HCO3- reabsroption.
• Diarrhea: Excess HCO3- loss into the feces without time to
reabsorb (most common cause).
• Diabetes mellitus: In the absence of normal glucose
metabolism the cells metabolize fats and form acetoacetic
acid, reducing pH, and inducing renal acid wasting.
• Chronic renal failure: decreased renal function results in acid
build-up in the circulation and reduced HCO3- reabsorption.
• Acid ingestion: toxins such as aspirin or methyl alcohol result
in excess acid formation.
 Metabolic
Primary [HCO3]
alkalosis
Source   ——impossible
Fixed acids From GI ：vomiting, gastric suction
K+ or Cl¯ deficiency
Loss 
Hyperaldosteronism
From kidney Cushing’s syndrome
Diuretic therapy

Source  ——Alkali administration：NaHCO3、

Bases sodium lactate .
Exclusion   ——impossible
Metabolic Alkalosis: occurs when there is excess retention
of HCO3- or excess loss of H+ from the body

• Diuretic therapy: many diuretics increase tubular flow,

resulting in increased Na load, increased Na reabsorption
and therefore increased HCO3- reabsorption.
• Excess Aldosterone: which promotes excess Na
reabsorption and stimulates H+ secretion.
• Vomiting: loss of the acidic contents of the stomach
creates a depletion of H+ which is compensated for by
removing more H+ from the circulation.
• Ingestion of alkaline drugs such as NaHCO3- used for
upset stomachs and ulcers.
 Loss of H+

Loss of Cl
Severe
vomiting Loss of K +

Loss body fluid

• Respiratory Acidosis is the inability of the lungs
to eliminate CO2 efficiently; so the equilibrium
shifts toward increased H+ and HCO3-; therefore,
pH decreases.
Respiratory Acidosis: ↗ CO2 + H2O  H+ + HCO3-

• Respiratory Alkalosis is excessive loss of CO2

through ventilation driving the equilibrium to the
left away from H+ therefore, pH increases.
Respiratory Alkalosis: ↘ CO2 + H2O  H+ + HCO3-
 Respiratory
acidosis Primary [H2CO3 or CO2 ] 

Exhalation  ：failure of ventilation

Volatile acid

inhalation ：inhale CO2 at high concentration

Respiratory
Primary [H2CO3 or CO2 ] ↓
alkalosis
hypoxemia, anxiety, hysteria,
Volatile acid Exhalation  Salicylate intoxication
CNS diseases
 The “metabolic” or renal regulation of the balance of H+ or
HCO3- excreted will determine if there is a net loss of H+ or
HCO3-, and will determine the pH of the urine.

CO2 + H2O  H+ + HCO3-

Filtered

Nephron

Secreted
Reabsorbed

Note: the renal regulation of the

equilibrium between H+ and CO2 takes
place on the “right” side of the
equation
Urine (excreted)
Overall, the kidneys must
excrete H+ and prevent
the loss of HCO3-.
Filtered HCO3- must react
with secreted H+ in order
to be reabsorbed as
H2CO3
 Mixed acid – base disorder
• Acidosis + alkalosis in a patient
• More than one acid base disturbance present
• pH may be normal or abnormal.
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