+] [H

Metabolism

Proximal tubule reabsorbs HCO3Distal tubule secretes H+ Lung disease and disorders of mechanics

of ventilation cause retention of CO2 Vomiting causes loss of H+

Summary statement
Acid-base physiology describes (1) how the lungs regulate arterial pCO2 in the face of variable CO2 production and (2) how the kidneys regulate arterial HCO3 by reabsorbing filtered bicarbonate and replacing bicarbonate lost in buffering acids
The goal is to maintain a pCO2 of 40 mm Hg and a bicarbonate of 24 mEq/L (mMol/L). This results in a pH of 7.4.

Endogenous acids
No one glows in the dark, TXU doesnt consider you to be a resource.
All equations must be charge neutral

Sources of non-volatile acids:

Organic cation to neutral: NH4+ urea + H+ S-containing amino acids to sulfuric acid
S SO4-2 + 2H+ pyruvate lactate + H+

Neutral compound to organic acid:

Endogenous acids
Organic anion to neutral product
Lactate + H+ pyruvate

Diet
CHO, fats: neutral (CO2 + H2O), small production of ketone bodies/lactate Proteins: major source of H+

Language of acid-base disorders

Acidemia, alkalemia Acidosis, alkalosis Respiratory (CO2) Metabolic (HCO3-) Normal pH= 7.40, normal pCO2 = 40, and

normal HCO3- = 24. When you try to understand a disorder you must start from here.

Acid-base rules
The pH is governed by the ratio of pCO2/HCO3 When working an acid-base problem, ALWAYS put the ratio pCO2/HCO3- down on paper first

[H+] = 24 (pCO2/HCO3) Henderson formula

The partner should travel in the same direction as the primary disturbance; e.g., If HC03- falls,

then the pCO2 should fall also.

Language of acid-base disorders

Compensation
If there is a primary disturbance in one of the pairs of the bicarbonate/carbonic acid buffer system, the other will attempt restoration of the pH by moving in the same direction.

You cannot compensate to normal; therefore YOU CANNOT OVER-COMPENSATE The kidneys compensate for changes in HCO3 The lungs compensate for changes in CO2

Acid-base rules
Always look at the pH first
If it is < 7.40 then you have an acidemia therefore there is an acidosis.
Only 2 ways to cause an acidosis:
pCO2 or HCO3-

If the pCO2>40, then respiratory acidosis

Compensation would be HCO3>24

If the HCO3- < 24, metabolic acidosis

Compensation would be pCO2<40

In a simple disorder, the compensating partner must move in the same direction as the culprit.

Acid-base rules
If pH > 7.40, then you have alkalemia,

therefore there is an alkalosis.

Only 2 ways to get one: pCO2 or HCO3 If pCO2<40, then respiratory alkalosis
Compensation would be HCO3<24

IF HCO3- >24, then metabolic alkalosis

Compensation would be pCO2>40

Acid-base rules
Primary

pCO2 pCO2 HCO3HCO3-

Compensation HCO3HCO3pCO2 pCO2

Acid-base rules
The compensating partner has five choices:
1. 2. 3. 4. 5. 6. 7. Change in the proper direction, but too far. Change in the proper direction, just right. Change in the proper direction but not far enough. Not change at all. Change in the . Only one of this is a simple disorder with appropriate compensation: #2. All of the others have a second primary disorder

Acid-base rules
1. Change too far: a second primary disorder.
2. Change just right, compensation. 3. Change too little, a second primary disorder.

4. Not change at all, a second primary disorder.

5. Change in the wrong direction, a second primary disorder.

Metabolic acidosis
1. Primary fall in HCO3- because of addition of H+-R- or
2.

3. 4.
5.

HCl If H+-R- added, then it leaves a tracks in the anion gap (the R-). AG= [Na+] ([Cl- + HCO3-]); normal is 10-15 The AG is made up of mostly anionic charges on albumin. What happens to the AG if the albumin concentration is low? If H+-R- was added, the HCO3- falls by the amount of Radded. Some like to call this BASE DEFICIT, DELTA BICARBONATE, etc. THERE IS NO REASON TO MAKE THIS DIFFICULT. REASON IT OUT.

Metabolic acidosis
Types of H+-Rlactic paraldehyde oxalic acid (ethylene glycol) salicylates ketones (diabetic, starvation, alcoholic) formic acid (methanol) uremic

Metabolic acidosis
Non-anion gap (hyperchloremic) Renal in origin: Renal Tubular Acidosis Proximal: defect in reclamation of HCO3-, normal acidification. Urine pH < 5.5 Distal: defect in acidification, normal HCO3- reclamation. Urine pH > 6.1 Both associated with hypokalemia Type IV: defect in acidification and in secretion of potassium: hyperkalemic Elderly, diabetic, hospitalized are the populations in which Type IV is usually seen.

Metabolic acidosis
If there is a metabolic acidosis (pH<7.4 and HCO3- < 24), what should the pCO2 be? Winters formula: ONLY IN METABOLIC ACIDOSIS Predicts the compensation of pCO2 pCO2exp =[ [HCO3- ] x 1.5] + 8 + 2 NONE OF THE OTHER RULES WORK.

Metabolic Acidosis
Example: if the HCO3- is 12 pCO2exp = [12 x 1.5] +8 + 2 = 26 +2 Using this example, it is a simple disorder if the pCO2 is 24-28 If the pCO2 < 24, then it is too far: therefore, a primary respiratory alkalosis If the pCO2 > 28, not far enough, therefore, a primary respiratory acidosis

Metabolic acidosis: problems

40 yo man admitted with RR of 30, Na+ 142, K+ 3.6, Cl- 100, HCO3- 12, pH 7.28, pCO2 26 Step 1. pH is acid, bicarbonate is low: metabolic acidosis
AG is 30, short differential

Step 2. Is there compensation? pCO2exp = [12 x 1.5] +8 + 2 = 26 + 2

Yes, this is a simple disorder.

Step 3. Causes?

Metabolic acidosis: problems

If the pH < 7.4, the HCO3- is 12, and the pCO2 = 34, what is the disturbance? Step 1 is the same. Acidemia, metabolic acidosis. Step 2 reveals that the pCO2 should be 24-28. It is not; there is now a primary resp acidosis Step 3. Why is there now resp failure? Step 4. What is the pH? [H+] = (24)(34/12)=68 nanoEq/L

Conversion of pH to [H+] etc. H+ pH 24 x 0.8 19 7.6 32 x 0.8 32 7.5 40 x 0.8 40 7.4 40 x 1.25 50 7.3 50 x 1.25 63 7.2 etc. 78 7.1 Very inaccurate below 7.1 or above 7.6

Metabolic acidosis: problems

What if the HCO3- is 12 and the pCO2 is 18? Step 1 is the same. pCO2exp= 12x1.5+8+2=26+2: (24-28) Step 2 reveals that the pCO2 is too low, therefore there is a primary resp alkalosis Step 3. Causes of met acid the same, why is there a primary resp alkalosis?

What is the new pH?

[H+] = 24 x 18/12 = 36 This is < 40 (neutral pH), therefore 40 x 0.8 = 32 = pH of 7.3 36 is halfway between 32 and 40, therefore the pH is halfway between 7.3 and 7.4 pH = 7.35

Metabolic alkalosis
Bicarbonate is filtered, reabsorbed proximally, and is generated distally. Met alkalosis requires 2 events:
Generation of bicarbonate Maintenance of hyperbicarbonatemia

Metabolic alkalosis
Generation events:
Loss of HCl in vomiting Cholera-like diarrhea Volume depletion Excess of aldosterone Post-hypercapnic

Metabolic alkalosis
Maintenance events: Something must raise the proximal tubules ability to increase reabsorption of increased filtered bicarbonate. Think of a dam. Maintenance events: hypokalemia, excess aldosterone, volume depletion, hypercapnia, No good rule for estimating the pCO2exp. In general, the pCO2 will not be above 50-55 torr unless oxygen is given.

Metabolic alkalosis
Treatment: Must identify the generation event and the maintenance event. Must treat both of them. Remember that metabolic alkalosis is usually associated with hypokalemia and hypochloremia. In all metabolic alkaloses that are not hypertensive or congenital, the volume status is low. The urine Cl- is helpful.

Metabolic alkalosis: problems

Na 140, K 3.0, Cl 86, HCO3 40, pH 7.52, pCO2 51.
1. pH > 7.40: alkalosis; bicarbonate >24: metabolic alkalosis 2. Did the pCO2 change in the same direction? 51<55 therefore probably compensation. AG = 14, no metabolic acidosis. 3. ALWAYS CALCULATE THE AG 4. Causes of generation and maintenance?

Respiratory disorders
Acute disorders cause a larger change in the pH than chronic disorders. Renal compensation may take 3 days to complete. Acute: for every pCO2 change of 10 the pH will change 0.08 pH units. As an example, if pCO2 falls, the pH will rise.
Chronic: for a pCO2 change of 10 the pH will change 0.04 pH units.

Respiratory disorders
Assume the patient has a pCO2 of 50, what should the pH be? If Acute: pCO2 change is 50-40=10. pH should be 7.32 (7.40-0.08 pH units). Chronic: pCO2 change is 50-40=10. pH should be 7.36 (7.40-0.04 pH units) Therefore, if the pH is between 7.32 and 7.36, you have a simple respiratory acidosis.

Respiratory disorders
Assume the patient has a pCO2 of 30, what should the pH be? Acute: pCO2 change is 40-30=10. pH should be 7.48 (7.40+0.08 pH units) Chronic: pCO2 change is 40-30=10. pH should be 7.44 (7.40+0.04 pH units) Therefore, if the pH is between 7.48 and 7.44, you have a simple respiratory alkalosis.

Summary
Always write down: pCO2/HCO3 Remember the partner should change in the same direction

Winters formula for metabolic acidosis only. pH change as function of pCO2 change. This lets you

bracket what compensation should be if it is a simple disorder. If the pH is outside this range, you have another primary disorder. Conversion of pH to [H+] ALWAYS, ALWAYS, CALCULATE THE ANION GAP