Acid-Base Disturbances

Posted by • October 10th, 2014

Acid–base homeostasis is fundamental for maintaining life. The first article in the new Disorders of Fluids and Electrolytes series reviews a stepwise method for the physiological approach to evaluation of acid–base status.

Internal acid-base homeostasis is fundamental for maintaining life. Accurate and timely interpretation of an acid-base disorder can be lifesaving, but establishment of a correct diagnosis may be challenging.

Clinical Pearls

What are some uses and limitations of the anion gap?

Lactic acidosis accounts for about half of the high anion gap cases, and is often due to shock or tissue hypoxia. The anion gap however, is a relatively insensitive reflection of lactic acidosis — roughly half the patients with serum lactate levels between 3.0 and 5.0 mmol per liter have an anion gap within the reference range. With a sensitivity and specificity below 80% in identifying elevated lactate levels, the anion gap cannot replace a serum lactate measurement. Nevertheless, lactate levels are not routinely drawn or always rapidly available, and a high anion gap can alert the physician that further evaluation is necessary. In addition, the anion gap should always be adjusted for the albumin concentration, because this weak acid may account for up to 75% of the anion gap. Without correction for hypoalbuminemia, the anion gap can fail to detect the presence of a clinically significant increase in anions (>5 mmol per liter) in more than 50% of cases. For every 1 g per deciliter decrement in serum albumin concentration, the calculated anion gap should be raised by approximately 2.3 to 2.5 mmol per liter.

Table 1. Primary Acid-Base Disturbances with a Secondary (“Compensatory”) Response. 

What are the characteristics of a normal anion-gap (hyperchloremic) acidosis?

Chloride plays a central role in intracellular and extracellular acid-base regulation. A normal anion-gap acidosis will be found when the decrease in bicarbonate ions corresponds with an increase in chloride ions to retain electroneutrality, also called a hyperchloremic metabolic acidosis. This type of acidosis occurs from gastrointestinal loss of bicarbonate (e.g., because of diarrhea or ureteral diversion), from renal loss of bicarbonate that may occur in defective urinary acidification by the renal tubules (renal tubular acidosis), or in early renal failure when acid excretion is impaired. Hospital-acquired hyperchloremic acidosis is usually caused by the infusion of large volumes of normal saline (0.9%). Hyperchloremic acidosis should lead to increased renal excretion of ammonium, and measurement of urinary ammonium can therefore be used to differentiate between renal and extrarenal causes of normal anion-gap acidosis. However, since urinary ammonium is seldom measured, the urinary anion gap and urinary osmolal gap are often used as surrogate measures of excretion of urinary ammonium. The urine anion gap ([Na+] + [K+] – Cl-]) is usually negative in normal anion-gap acidosis, but it will become positive when excretion of urinary ammonium (NH4+) (as ammonium chloride [NH4Cl]) is impaired, as in renal failure, distal renal tubular acidosis, or hypoaldosteronism.

Morning Report Questions

Q: What is a useful approach to the analysis and treatment of a metabolic alkalosis?

A: The normal kidney is highly efficient at excreting large amounts of bicarbonate, and accordingly, the generation of metabolic alkalosis requires both an increase in alkali and impairment in renal excretion of bicarbonate. Gastric fluid loss and diuretic use account for the majority of metabolic alkalosis cases. By measuring chloride in urine, one can distinguish between chloride-responsive and chloride-resistant metabolic alkalosis. If the kidneys perceive a reduced “effective circulating volume,” they avidly reabsorb filtered sodium, bicarbonate, and chloride, largely through activation of the renin-angiotensin-aldosterone system, thus reducing the concentration of urinary chloride. A (spot sample) urinary chloride concentration of less than 25 mmol per liter is reflective of chloride-responsive metabolic alkalosis. Administration of fluids with sodium chloride (usually with potassium chloride) restores effective arterial volume, replenishes potassium ions, or both with correction of metabolic alkalosis. Metabolic alkalosis with a urinary chloride concentration of more than 40 mmol per liter is mainly caused by inappropriate renal excretion of sodium chloride, often reflecting mineralocorticoid excess or severe hypokalemia (potassium concentration <2 mmol per liter). The administration of sodium chloride does not correct this type of metabolic alkalosis, which, for that reason, is called “chloride-resistant.” Diuretic-induced metabolic alkalosis is an exception because the concentration of chloride in urine may increase initially, until the diuretic effect wanes, after which the concentration of chloride in the urine will fall below 25 mmol per liter.

Figure 2. Assessment of Alkalosis.

Q: How is the “delta anion gap” helpful in the evaluation of mixed metabolic acid-base disorders?

A: In high anion-gap metabolic acidosis, the magnitude of the anion gap increase (delta AG) is related to the decrease in the bicarbonate ions (delta[HCO3-]). To diagnose a high anion-gap acidosis with concomitant metabolic alkalosis or normal anion-gap acidosis, the so-called delta-delta may be used. The delta gap is the comparison between the increase (delta) in the anion gap above the upper reference value (e.g., 12 mmol per liter) and the change (delta) in the concentration of bicarbonate ions from the lower reference value of bicarbonate ions (e.g., 24 mmol per liter). In ketoacidosis, there is a 1:1 correlation between the rise in anion-gap and the fall in concentration of bicarbonate. In lactic acidosis, the decrease in concentration of bicarbonate is 0.6 times the increase in anion gap (e.g., if the anion gap raises 10 mmol per liter, the concentration of bicarbonate should decrease about 6.0 mmol per liter). This difference is probably due to the lower renal clearance of lactate compared with keto-anions. Hydrogen buffering in cells and bone takes time to reach completion. Accordingly, the ratio may be close to 1:1 with “very acute” lactic acidosis (as with seizures or exercise to exhaustion). If the delta AG – delta[HCO3-] in ketoacidosis or if 0.6 delta AG – delta[HCO3-] in lactic acidosis = 0+/-5 mmol per liter, simple anion-gap metabolic acidosis is present. A difference greater than 5 mmol per liter suggests a concomitant metabolic alkalosis, and if the difference is less than -5 mmol per liter, a concomitant normal anion-gap metabolic acidosis is diagnosed.

7 Responses to “Acid-Base Disturbances”

  1. dr suryakant dhoke says:

    Vital and clinical metabolic acid base information usrful at bedside and for practical use,nice.

  2. eduardo navarrete says:

    Que debo hacer con un paciente con un lactato de 16, ph 4.42 y glucosa 528?????

  3. Wayne Baldwin says:

    What fluid regimen might be recommended for care of the West African Ebola Outbreak patient in treatment centers with neither laboratory nor invasive fluid resources?

  4. Roberto Coste says:

    Me gusta ver y leer, todo lo de medicina, gracias por las publicaciones, muy instructivas.

  5. Dr DK Jha says:

    Very useful information

  6. AC says:

    Ah yes, Acid Base disturbances– a resident’s bane, a constant fear that attendings and nephrologists love to pimp on. Especially during morning rounds before the caffeine has set in and you’re behind on 3 notes because sign out from the overnight team took twice as long as you thought!!!

  7. dr ankit gajjar says:

    Very nice article…
    Thanx to NEJM..
    Can you tell me, why we are using urine chloride for type of metabolic alkalosis??? Why not urine sodium???