1. Acid-base Balance and its Disorders Prof. Dr. Meltem Pekpak

2. For optimal functioning of cells.. Acids and bases in the body must be in balance. We all consume every day food and drinks which contain acids, metabolism produces also acids...

3. Body pH Balance Chemical blood buffers: Lungs, Cells, Kidneys Defences against changes in hydrogen concentration (getting acidotic..)

4. You get acidotic every day ! While living, eating and drinking...there is.. Production of 1 mmol of fixed acid/kg body weight per day (60 kg=60 mmol/day)

5. Buffers Extracellular: Hemoglobin – (‘Chloride shift’-for each chloride leaving the cell-one bicarbonate ion enters) Plasma protein –(with the liver, varying the amount of H-ions in the protein structure) Bicarbonate system: –Normal acid to base ratio is 20:1 –20 parts bicarbonate to 1 part carbonic acid (H 2 CO 3 =CO 2 ), –Neutralizing a strong acid bicarb. will be lost

6. Human Acid-base Homeostasis Tight regulation: CO 2 tension –by respiratory excretion (of volatile acids) Plasma bicarbonate [HCO 3 - ] –By renal HCO 3 - reabsorption and –Elimination of protons produced by metabolism pH is determined by CO 2 tension and [HCO 3 - ]

7. Physiology of Buffering: Ability of a solution containing a weak or poorly dissociated acid and its anion (a base) to resist change in pH when strong acid or alkali is added 1 ml of 0.1 M HCl to 9 ml distilled water = [H + ] from 10 -7 M to 10 -2 M= pH from 7 to 2 1 ml of 0.1 M HCl to 9 ml of phosphate buffer: dissoc. H + combines with [HPO 4 2- ] = (H 2 PO 4 - ) pH fall of only 0.1= to 6.9

8. Bicarbonate Buffer Extracellular most important buffer Proteins and phosphate buffer less important Intracellular phosphate- most important b. Equilibrium conditions because abundant carbonic anhydrase in blood H + + HCO 3 -  H 2 CO 3  H 2 O + CO 2 [H + ]= Keq x [H 2 CO 3 ]/[HCO 3 - ]

9. Equations H + + HCO 3 -  H 2 CO 3  H 2 O + CO 2 Equilibrium [H + ]= Keq x [H 2 CO 3 ]/[HCO 3 - ]

10. Total Acid- base Metabolism Henderson-Hasselbalch 1909,1916 HCO 3 - pH = pK + log ------------ PaCO 2 Result of Metabolic and Respiratory Interplay Primary Respiratory Disorders Altered by Respiratory Compensation for Metabolic Disorders Metabolic comp. Respiratory component Altered by Buffering Primarily Altered in Metabolic Disorders

11. Normal Values [HCO 3 - ] ~ 24 mM PaCO 2 = 38 torr pH ~ 7.42 Plasma HCO 3 - regulation by –reclaiming filtered HCO 3 - and –generating new HCO 3 - (carboanhydrase) – ( to replace the lost internally titrating metabolic acid and externally from the GI tract) Production of 1 mmol of acid/kg body weight per day (60 kg=60 mmol/day)

12. Renal Acid -base Handling Two seperate functions: Bicarbonate reabsorption Net acid secretion

13. Proximal Tubular Bicarbonate Reclamation Process (90 %) Two vehicles for apical H + secretion (Na + /H + exchanger), H + ATPase. Basolateral ion pumps: Na + /K + ATPase, (Na + HCO3 - )symporter,HCO3 - /Cl - Exchanger. The role of carbonic anhydrase (CA) in tubular cell and brush border

14. Net Acid Excretion Urine is acid = pH~ 4.5 Buffer salts are in the tubular fluid Phosphate is the most important buffer in urine: HPO 4 2- + H + = H 2 PO 4 - Nonvolatile (fixed) acids (anions= sulfates, phosphates) must be accompanied in the urine by equivalent cations (Na +, K +, Ca + +) for maintenance of electrical neutrality In acid urine ammonium helps to keep [H + ] (ammonia NH 3 + to NH 4 + )

15. Clinical Evaluation Patient history Clinical presentation Acidemia  Hyperventilation Alkalemia  Paresthesias and Tetany Laboratory: Blood acid-base status: Blood pH (4 º C, with anticoagulant, promptly), Urine pH Plasma and urine electrolyte concentration Lactate concentration

16. Acidosis Clinical effects of severe acidosis: pH <7.2 Cardiovascular system effects: Decreased myocardial contractility Decreased cardiac output Cardiac failure Hypotension Decreased hepatic and renal blood flow Centralization of effective blood volume Tissue hypoxia Pulmonary edema

17. Metabolic acidosis Hallmark is  [HCO 3 - ] 1. Acid production  net acid intake  above net renal excretion (ketoacidosis, lactic acidosis, ammonium chloride loading) 2. failure of renal net excretion (chronic renal failure, renal tubular acidosis) 3. Bicarbonate loss via the gastroinestinal tract (diarrhea, gastrointestinal fistula) 4. Nonbicarbonate solutions added to ECF (dilutional acidosis)

18. Steps of evaluation 1. Examine pH= Reduction ( 7.2)  Acidosis Increase (7.5)  Alkalosis 2. Examine directional change of PCO 2 and [HCO 3 - ], pH acid, HCO 3 - low  Metabolic acidosis pH alkal., HCO 3 - high  Metabolic alkalosis 3. Assess degree of compensation: Mixed acid-base disorder? Metabolic acidosis  PCO 2  Metabolic alkalosis  PCO 2  Failure of respiratory compenstion= primary respiratory acid-base disorder Never to initial pH through compensation !!

19. 4. Calculate the serum anion gap Is the acid-base disorder organic or mineral in origin?? We use venous sample blood electrolytes: Electroneutrality demands: Serum anion gap, that means: [Na + ] + [UC]= [Cl - ] +[Total CO 2 ] + [UA] (U means: unmeasured) Steps of evaluation

20. Normally the serum anion gap is about 9 (6-12 mEq/l), a major increase in Anion gap > 26 mEq/l always implies existence of an organic acidosis

21. Differential Diagnosis of Metabolic Acidosis Normal anion gap Increased anion gap (hyperchloemic) (organic)_________ GI loss of HCO 3 -  acid production Diarrhea Lactic acidosis Renal tub. Acidosis Diab. Ketoacidosis Parenteral alimentationToxic alcohol,salicy. Carbonic anhydr. İnh. Acute renal failure K-sparing diureticsChronic renal failure

22. Increased anion gap Metabolic acidosis Ketoacidosis (diabetic) Uremia (renal failure) Salicylate intoxication Starvation Methanol intoxication Alcohol ketoacidosis Unmeasured osmoles (intoxication) Lactic acidosis

23. Simple decompensated Acid-base Disorders Acid Base Dis.: pH pCO 2 HCO 3 - Metabolic acidosis    Respiratory acidosis   Metabolic alkalosis    Respiratory alkalosis  

24. Compensatory Response one half of acid load is buffered by nonbicarbonate buffers= Bone, protein, red cells.. PCO 2  (Kussmaul) compensatory response after 15-30 minutes, 5 days up to maximal Kidney: Metabolic acidosis  processing of glutamine into NH 4 + (ammonia to ammonium for better H-excretion) and Bicarbonate generation (and reclaiming)

26. Respiratory Acidosis Acute increase in pCO 2 Buffered primarily by intracellular buffers Chronic state: Kidneys compensation: Increase net acid excretion, (48 hours for fully development) Underlying cause: Central nervous system disease, lung (COPD)and heart disease, sedatives and opiates depressing the respiratory center Hypercapnic encephalopathy can develop

27. Metabolic Alkalosis Plasma bicarbonate [HCO 3 - ]  = pH  1) H + GI loss or shift into cells 2) Excess HCO 3 - Administration of  bicarbonate, or precursors:  lactate, acetate, citrate or Failure to excrete: mineralocorticoid effect 3) Loss of fluid with Diuretic therapy [Cl - ], [K + ] and [H + ] loss from plasma- extracellular volume contraction

28. Alkalosis

29. Volume Depletion and Metabolic Alkalosis Absolute volume depletion: Loss of salt by bleeding or vomitting or Effective volume depletion: Heart failure, cirrhosis, nephrotic syndrome    whenever   GFR  Tubular HCO 3 - reabsorption Because proximal tubule reabsorption is enhanced for Na and water

30. Compensatory Respiratory Response Alveolar hypoventilation(hypercapnia) (limited pCO 2 rise to 50-60 mm Hg) Kidneys: Excretion of HCO 3 - proportional to GFR (excessive)

31. pCO2 , pH  due to: Hypoxia (compensatory hyperventilation) Acute: pulmonary edema or emboli, pneumonia, Chronic: severe anemia, high altitude, hypotension Respiratory center stimulation Pregnancy, Anxiety, Fever, heat stroke, sepsis, salisylate intox., cerebral disease, hepatic cirrhosis, Increased mechanical ventilation Respiratory Alkalosis

32. Most common acid-base disorder Physiologic in pregnancy and high altitude Bad prognosis in critically ill patients (the higher hypocapnia, the higher mortality) Hyperventilation, Perioral and extremity paresthesias, Light-headedness, Muscle cramps, Hyperreflexia, seizures,  ionized Ca  tetany

33. Metabolic Alkalosis with and without Volume Depletion Volume depleted- Chloride responsive metabolic acidosis: Urine chloride is low (<10 mmol/l) Due to: Gastric fluid losses Stool losses Diuretic therapy

34. Metabolic Alkalosis Excessive Mineralocorticoids Mineralocorticoids stimulate hydrogen ion secretion And this bicarbonate reabsorption Urinary chloride is normal (<20 mmol/l) Hypokalemia Primary aldosteronizm, Bartter’s Syndrome, Cushing Syndrome Renovascular hypertension

36. The proximal tubulus cells form carbonic acid from carbon dioxide and water under the influence of the enzyme carboanhydrase (CA). Carbonic acid ionizes to yield hydrogen and bicarbonate. Hydrogen formed in the cell exchanges with sodium in the tubular fluid (dashed circle). As a net effect Sodium bicarbonate is reabsorbed, and the hydrogen ion secreted into the tubular lumen is buffered by filtered bicarbonate. Proximal Tubular Bicarbonate Reclamation Process (90 %)

37. Henderson-Hasselbach 1909,1916 H 2 CO 3 = p CO 2 + solubility in physiol. Fluids [H + ]= K x [S x pCO 2 ]/[HCO 3 - ] Antilog of both sides: pH= pK + log 10 [HCO 3 - ] / [S x PCO 2 ] In blood at 37º C, pK =6.1 and S is 0.03 pH= 6.1+ log 10 [HCO 3 - ] / [0.03 x PaCO 2 ]