The extrarenal correction of alkalosis associated with potassium deficiency

Evaluation and Management of Hyponatremia in Heart Failure

PURPOSE OF REVIEW

To provide a contemporary overview of the pathophysiology, evaluation, and treatment of hyponatremia in heart failure (HF).

RECENT FINDINGS

Potassium and magnesium losses due to poor nutritional intake and treatment with diuretics cause an intracellular sodium shift in HF that may contribute to hyponatremia. Impaired renal blood flow leading to a lower glomerular filtration rate and increased proximal tubular reabsorption lead to an impaired tubular flux through diluting distal segments of the nephron, compromising electrolyte-free water excretion. Hyponatremia in HF is typically a condition of impaired water excretion by the kidneys on a background of potassium and magnesium depletion. While those cations can and should be easily repleted, further treatment should mainly focus on improving the underlying HF and hemodynamics, while addressing congestion. For decongestive treatment, proximally acting diuretics such as sodium-glucose co-transporter-2 inhibitors, acetazolamide, and loop diuretics are the preferred options.

Respiratory adjustment to chronic metabolic alkalosis in man

This study examined the ventilatory adjustment to chronic metabolic alkalosis induced under controlled conditions in normal human volunteers. Metabolic alkalosis induced by buffers (sodium bicarbonate, trishydroxymethylamine methane) or ethacrynic acid was associated with alveolar hypoventilation, as evidenced by a rise in arterial Pco(2), a fall in arterial Po(2), a reduced resting tidal volume, and a diminished ventilatory response to CO(2) inhalation. Alveolar hypoventilation did not occur when metabolic alkalosis was induced in the same subjects by thiazide diuretics or aldosterone despite comparable elevations of the arterial blood pH and bicarbonate concentration.The different ventilatory responses of the two groups could not be ascribed to differences among individuals comprising each group, pharmacological effects of the alkalinizing agents, differences in the composition of the lumber spinal fluid, changes in extracellular fluid volume, or sodium and chloride balance.The differences in ventilatory adjustments were associated with differences in the patterns of hydrogen and potassium ion balance during the induction of alkalosis. Alveolar hypoventilation occurred when hydrogen ions were buffered (sodium bicarbonate, trishydroxymethylamine methane) or when renal hydrogen ion excretion was increased (ethacrynic acid). Alveolar hypoventilation did not occur when induction of similar degrees of extracellular alkalosis was accompanied by marked potassium loss and no demonstrable increase in external hydrogen loss (thiazides and aldosterone).These observations suggest that respiratory depression does not necessarily accompany extracellular alkalosis but depends on the effect of the mode of induction of the alkalosis on the tissues involved in the control of ventilation.

Potassium depletion increases luminal Na+/H+ exchange and basolateral Na+:CO3=:HCO3- cotransport in rat renal cortex

Most HCO3- reabsorption in proximal tubules occurs via electroneutral Na+/H+ exchange in brush border membranes (BBMS) and electrogenic Na+:CO3=:HCO3- cotransport in basolateral membranes (BLMS). Since potassium depletion (KD) increases HCO3- reabsorption in proximal tubules, we evaluated these transport systems using BBM and BLM vesicles, respectively, from control (C) and KD rats. Feeding rats a potassium deficient diet for 3-4 wk resulted in lower plasma [K+] (2.94 mEq/liter, KD vs. 4.47 C), and higher arterial pH (7.51 KD vs. 7.39 C). KD rats gained less weight than C but had higher renal cortical weight. Influx of 1 mM 22Na+ at 5 s (pHo 7.5, pHi 6.0, 10% CO2, 90% N2) into BLM vesicles was 44% higher in the KD group compared to C with no difference in equilibrium uptake. The increment in Na+ influx in the KD group was DIDS sensitive, suggesting that Na+:CO3=:HCO3- cotransport accounted for the observed differences. Kinetic analysis of Na+ influx showed a Km of 8.2 mM in KD vs. 7.6 mM in C and Vmax of 278 nmol/min/mg protein in KD vs. 177 nmol/min/mg protein in C. Influx of 1 mM 22Na+ at 5 s (pHo 7.5, pHi 6.0) into BBM vesicles was 34% higher in the KD group compared to C with no difference in equilibrium uptake. The increment in Na+ influx in the KD group was amiloride sensitive, suggesting that Na+/H+ exchange was responsible for the observed differences. Kinetic analysis of Na+ influx showed a Km of 6.2 mM in KD vs. 7.1 mM in C and Vmax of 209 nmol/min/mg protein in KD vs. 144 nmol/min/mg protein in C. Uptakes of Na(+)-dependent [3H]glucose into BBM and [14C]succinate into BLM vesicles were not different in KD and C groups, suggesting that the Na+/H+ exchanger and Na+:CO3=:HCO3- cotransporter activities were specifically altered in KD. We conclude that adaptive increases in basolateral Na+:CO3=:HCO3- cotransport and luminal Na+H+ exchange are likely responsible for increased HCO3- reabsorption in proximal tubules of KD animals.

Change of intracellular K+ activity in rat soleus muscle during hypokalemia

The relationship between intracellular total K+ concentration [( K]i) as determined by a flame spectrophotometer and intracellular K+ activity (aKi) as determined by an ion-selective microelectrode was studied in soleus muscle of rats on a diet deficient in K+ for 40 days. [K]i began to fall immediately from the initial stage of hypokalemia, while aKi was well-maintained for 15 days. Then, aKi decreased gradually. The measured resting potential (Em) hyperpolarized beyond the EK was calculated from aKi in hypokalemic rat muscle from day 20 to 40. A rapid increase in aKi occurred over 3 hours in soleus muscle of hypokalemic rats for 5 to 6 weeks. It was concluded that the bound intracellular K+ acts as a buffer for aKi in hypokalemic rat muscle, that Em exceeds EK because the Na+-K+ pump is stimulated by increased [Na]i and that the increase in aKi after denervation is due to the removal of a Na+-K+ pump inhibitor normally released from nerve ending.

On the mechanism by which chloride corrects metabolic alkalosis in man

To determine whether administration of chloride corrects chloride-depletion metabolic alkalosis (CDA) by correction of plasma volume contraction and restoration of glomerular filtration rate or by an independent effect of chloride repletion, CDA was produced in normal men by the administration of furosemide and maintained by restriction of dietary sodium chloride intake. Negative sodium balance (-112 +/- 16 meq) and reduced plasma volume (2.53 versus 2.93 liters, p less than 0.05) developed. The cumulative chloride deficit of 271 +/- 16 meq was then repleted by oral potassium chloride (267 +/- 19 meq) over 36 hours with continued serial measurements of glomerular filtration rate, effective renal plasma flow, plasma volume, body weight, and plasma renin and aldosterone levels. CDA was corrected, even though body weight, plasma volume, glomerular filtration rate, and renal plasma flow all remained reduced and plasma aldosterone was elevated; urinary bicarbonate excretion increased during correction. Administration of an identical potassium chloride load to similarly sodium-depleted but not chloride-depleted normal subjects produced no change in acid-base status. It is concluded that chloride repletion can correct CDA by a renal mechanism without restoring plasma volume or glomerular filtration rate or by altering sodium avidity.

Mechanisms and regulation of ion transport in the renal collecting duct

1. In the present paper the ion transport function of the renal mammalian collecting duct and its regulation is briefly reviewed. 2. The epithelium is characterized by different cell types: principal cells, intercalated cells, type A, and intercalated cells, type B. 3. Using microelectrodes and various microscopic techniques active Na+ absorption as well as K+ secretion has been localized to the principal cells, while Cl- absorption was found to proceed largely, though not exclusively, through the tight junctions between cells. 4. Intercalated cells of type A, which prevail in the outer medullary collecting duct, secrete H+ and intercalated cells of type B, which are most frequent in the late cortical collecting duct, secrete HCO3-. 5. This specialization of different cells in transporting individual ions provides the basis for the efficient adaptive regulation of urinary ion excretion.

The influence of potassium and bicarbonate on red blood cell sodium in the DOCA-hypertensive pig

The effects of plasma potassium, and blood bicarbonate on red blood cell sodium were studied in vivo in seven pigs implanted subcutaneously with DOCA (100 mg/kg) impregnated in Silastic. Mean arterial pressure, red blood cell sodium, plasma sodium, plasma potassium, and blood bicarbonate were measured from 5 days pre-implant to 30 days post-implant. One day post-implant, the pigs had significant increases in mean arterial pressure and red cell sodium content, and a significant decrease in plasma potassium concentration. In KCl infusion studies when plasma potassium was raised an average of 2.13 +/- 0.17 mEq/L, red blood cell sodium fell 0.61 +/- 0.10 mEq/L cells. When blood bicarbonate was raised 6.9 mEq/L by infusing NaHCO3, red blood cell sodium increased 0.79 mEq/L cells. The changes in red blood cell sodium were rapid, occurring within one hour after either of these plasma electrolyte shifts. We conclude that either plasma potassium or blood bicarbonate, or both, can serve as regulators of red blood cell sodium content in vivo, and cause the elevated level of red blood cell sodium that we have found in the DOCA-hypertensive pig. If these plasma electrolyte changes cause a similar increase in intracellular sodium in vascular smooth muscle or in a blood pressure regulating center in the brain, they may play a role in producing the arterial pressure elevation of mineralocorticoid-induced hypertension.

Dietary NaCl determines severity of potassium depletion-induced metabolic alkalosis

It is uncertain whether, in humans, potassium depletion can cause or sustain metabolic alkalosis of clinically important degree in the absence of coexisting known alkalosis-producing conditions. Previously we found, in normal humans ingesting abundant NaCl, that dietary K+ depletion alone can induce and sustain a small decrease in blood acidity and increase in plasma bicarbonate concentration; we hypothesized that more severe alkalosis was prevented by mitigating mechanisms initiated by renal retention of dietary NaCl that was induced by K+ depletion. To ascertain the acid-base response to dietary K+ depletion under conditions in which the availability of NaCl for retention is greatly limited, in the present study of six normal men we restricted dietary K+ as in the previous study except that intake of NaCl was maintained low (2 to 7 mEq/day, Low NaCl Group) instead of high (126 mEq/day, High NaCl Group). Plasma acid-base composition and renal net-acid excretion (NAE) did not differ significantly between groups during the control period. In the steady state of K+ depletion (days 11 to 15 of K+ restriction), neither plasma K+ concentration (2.9 +/- 0.9 mEq/liter vs. 3.0 +/- 0.1 mEq/liter) nor cumulative K+ deficit (399 +/- 59 mEq vs. 466 +/- 48 mEq) differed significantly between groups. During K+ restriction, persisting metabolic alkalosis developed in both groups, which was more severe in the Low NaCl Group: increment in [HCO3-]p, 7.5 +/- 1.0 mEq/liter versus 2.0 +/- 0.3 mEq/liter, P less than 0.001; decrement in [H+]p, 5.5 +/- 0.6 nEq/liter versus 2.9 +/- 0.4 nEq/liter, P less than 0.003. A significantly more severe alkalosis in the Low NaCl Group was evident at all degrees of K+ deficiency achieved during the course of the 15 days of K+ restriction, and the severity of alkalosis in the Low NaCl Group correlated with the degree of K+ deficiency. During the generation of alkalosis (days 1 to 7 of K+ restriction), NAE increased in the Low NaCl Group whereas it decreased in the High NaCl Group. During the maintenance of alkalosis (days 11 to 15), NAE stabilized in both groups after it returned to values approximating the control values. In both groups, urine Cl- excretion decreased during K+ restriction even though Cl- intake had not been changed, with the result that body Cl- content increased negligibly in the Low NaCl Group (28 +/- 6 mEq) and substantially in the High NaCl Group (355 +/- 64 mEq).(ABSTRACT TRUNCATED AT 400 WORDS)

Hypokalemia modulates alpha- and beta-adrenoceptor bindings in rat skeletal muscle

Changes in the population of adrenergic alpha- and beta-receptors were examined in rat soleus muscles during hypokalemia by their direct determination using radiolabeled ligands. Only beta-adrenoceptors were detected in the normal rat muscles. Hypokalemia led to a pronounced decrease in beta-adrenoceptors, the number of [3H]DHA binding sites, by 50%, as compared with that in the normal rats. There was a genesis of alpha 1-adrenoceptors in hypokalemic rat muscles, since the competitive potency of adrenergic drugs against [3H]prazosin binding was in the order prazosin much greater than phentolamine greater than (+/-)-noradrenaline greater than yohimbine much greater than (+/-)-isoproterenol. The reduction of [3H]DHA binding sites was accompanied by an increase of an approximately equal amount in high-affinity [3H]prazosin binding sites. The Kd determined by kinetic analysis of [3H]prazosin binding was calculated from the ratio K-1/K1 that gave a value of 3.05 nM, which generally agreed with the 1.83 nM determined by saturation experiments (Scatchard plot). This phenomenon of a reduction in the beta-adrenoceptors and the occurrence of alpha 1-adrenoceptors in muscles during hypokalemia is discussed. alpha- and beta-adrenoceptors on soleus muscle membrane may play important but opposite roles in modulating potassium release from the muscle cells.

The electrogenic Na-pump and spontaneous contraction of the hypokalemic rat duodenum

The effects of the electrogenic Na-pump on spontaneous contraction in the isolated, longitudinal muscle of the duodenum of rats which had been on a potassium-deficient diet for 7 weeks, have been investigated. Intracellular levels of Na+ are increased by this diet. The spontaneous contraction of the duodenal muscle was stopped, transiently, by 0.5 to 120 mM-K+ Krebs solution. The period of decrease of tone and amplitude occurring immediately after adding K+ was shortened when the external K+ concentration ([K]o) was increased from 0.5 to 120 mM. The decrease in tone and amplitude induced by K+ was abolished by exposure of the tissue to 0 mM [K]o, by exposure to a temperature below 14 degrees C, and in the presence of ouabain (3 X 10(-5)-10(-4) M). The spontaneous contraction of 'Na-rich' duodenum in bathing medium containing 15 mM K+ and following inhibition of the electrogenic Na-pump with cooling or ouabain was much the same as in the duodenum from rats fed balanced diets: i.e., increase of contractile tone immediately after adding K+. To activate the Na-pump in 'Na-rich' duodenum, the external K+ could be replaced by Rb+, Cs+, NH4+ and Tl3+. The effectiveness was in the order K+ greater than Rb+ greater than Cs+ greater than NH4+ greater than Tl3+. The possible existence of a neuronal or hormonal inhibitory mechanism affecting the active Na-K transport in rat smooth muscle in situ, under conditions of hypokalemia, is discussed.

Muscle cell growth and the distribution of water and electrolyte in human pregnancy

Ten normal pregnant women had muscle composition analyses (rectus abdominis) carried out at 39-40 weeks of pregnancy. Water, chloride (Cl), chloride space (ECV), non-chloride space (ICW), potassium (K), sodium (Na), magnesium (Mg) and zinc (Zn) determinations were carried out. Analyses for DNA (cell number), protein: DNA ratio (cell size), RNA and collagen were also performed. Similar analyses were performed on uterine muscle and placentae before and after perfusion with Earle's solution. Data from pregnant patients were compared with similar estimations carried out on rectus abdominis samples from 13 non-pregnant subjects undergoing gynaecological procedures. Muscle tissue and predicted muscle mass (MM) (which constitutes 40% of body weight) demonstrated that the gain in body K was due to the products of conception, that ICW decreased per unit weight in muscle (8%), ECV increased (41%) without a radical change in muscle water content (2%). Overall a 6 l gain in ECV and a 2 l gain in ICW can be accounted for during pregnancy. The results of this study indicate that added hydration excluding the products of conception (placenta, infant, uterus) is mainly extracellular. Intracellular Na concentration decreases (50%) and it is speculated that the cation gap is made up by H+ in the presence of extracellular alkalosis. Muscle cells diminish in size but cell number per gram is constant. Zinc content (Zn/DNA) decreases. Previous experimental work suggests that MM increases by about 10% during pregnancy and this information has been included in considerations but it remains to be shown to what extent total muscle cell numbers increase and as to whether such increased muscle growth remains following pregnancy.

Neural regulation on the active sodium-potassium transport in hypokalaemic rat skeletal muscles

C.N.S.-induced suppression of muscle Na-pump activity was studied in fast 'twitch' muscle, extensor digitorum longus, of hypokalaemic rats which were fed a K-deficient diet for 0-9 weeks. The results were compared with those of slow 'tonic' muscle, soleus, reported previously. K-deficient diet caused blood hypokalaemia and a considerable K+ loss and Na+ accumulation in the skeletal, heart and smooth muscles. The cellular K+ loss was in the order of soleus greater than extensor digitorum longus greater than diaphragm greater than duodenum greater than auricle greater than ventricle; C.N.S. organs such as cerebrum, cerebellum, medulla oblongata, spinal cord and liver were spared this K+ fall. Skeletal, heart and smooth muscles lost more K+ with prolongation of hypokalaemic periods, whereas plasma K+ concentration did not fall much below 1.6 mM during hypokalaemia. Peripheral nerve section, cervical and brain-stem transection, decerebration and cortical spreading depression with 20% KCl, which activated the active Na+ and K+ transport in soleus muscles during hypokalaemia, could not enhance the pump activity in extensor digitorum longus muscles. Alpha-adrenoreceptor antagonists such as phenoxybenzamine, phentolamine and dibenamine and a specific blocker of post-synaptic alpha 1-adrenoreceptor, prazosin, did not stimulate Na+ and K+ transport in the extensor digitorum longus muscles during hypokalaemia while the beta-adrenoreceptor antagonist, propranolol, also had no effect. The sensitivity of the active Na+ and K+ transport system in rat muscles to ouabain applied intraperitoneally was greater in extensor digitorum longus muscles than in soleus muscles. The binding experiment with a radiolabelled ligand of alpha 1 adrenoreceptor antagonist, [3H]prazosin, demonstrated the presence of alpha 1-adrenergic receptors on the soleus muscle membranes of hypokalaemic rats, but not of normal rats. alpha 1 Adrenergic receptors were not detected on the extensor digitorum longus muscle membranes prepared from either hypokalaemic or normal rats. The correlation between the C.N.S.-induced inhibition on the Na pump in soleus muscle during hypokalaemia and the occurrence of alpha 1 adrenergic receptors on the muscle was discussed.

Red blood cell alkalosis and decreased oxyhemoglobin affinity

The behavior of the oxyhemoglobin curve was studied in ten patients with respiratory alkalosis (arterial [H+] less than 37 nM, pCO2 less than 32 mmHg and HCO-3 less than 22.0 mEq/L) and ten patients with metabolic alkalosis ([H+] less than 34 nM, pCO2 greater than 37 mmHg and HCO-3 greater than 28.0 mEq/L) to determine whether different alkalotic states similarly affect the red blood cell [H+] and 2,3-diphosphoglycerate interaction and thus the oxygen affinity of hemoglobin. The findings were statistically indistinguishable in respiratory alkalosis and metabolic alkalosis: a) low plasma [H+], normal red blood cell [H+], and high transmembrane [H+] gradient; b) elevated red blood cell 2,3-diphosphoglycerate inversely proportional to low arterial plasma [H+]; c) decrease in oxygen affinity of hemoglobin when normalized for plasma [H+], but less decreased when normalized for red blood cell [H+]. Other factors capable of affecting the oxygen affinity of hemoglobin were: mean corpuscular hemoglobin concentration; red blood cell adenosine triphosphate; carboxyhemoglobin; and methemoglobin were not significantly different between groups. These results: 1) agree with data previously reported from this laboratory on patients with portal-systemic encephalopathy; 2) underscore the importance of RBC [H+] in defining the oxygen affinity of hemoglobin; 3) suggest the decrease in oxygen affinity of hemoglobin is mediated through the 2,3-diphosphoglycerate elevation; and 4) indicate the high transmembrane [H+] gradient is principally due to the cellular accumulation of [H+] (2,3-diphosphoglycerate ionization).

Element concentrations of renal and hepatic cells under potassium depletion

The effect of dietary potassium depletion on nuclear and cytoplasmic element concentrations in cortical renal tubular cells and hepatocytes was investigated using electron microprobe analysis. Significant differences in sodium and potassium concentrations between nucleus and cytoplasm were not detected either under control or under potassium-depleted conditions. Potassium depletion for at least 14 days resulted in a decrease in plasma potassium concentration from 4.4 +/- 0.1 to 2.0 +/- 0.1 mmoles X liter-1. There was a fall in cellular potassium from 151.6 +/- 3.5 to 120.2 +/- 2.1 in distal tubular cells, from 150.1 +/- 2.6 to 117.7 +/- 1.2 in proximal tubular cells, and from 140.6 +/- 1.3 to 128.0 +/- 1.3 mmoles X kg-1 of wet wt in hepatocytes. The cellular chlorine concentrations fell from 19.9 +/- 0.7 to 15.8 +/- 0.3 and from 21.3 +/- 0.4 to 17.2 +/- 0.4 in proximal tubular and liver cells, respectively, but remained unchanged at 11.4 +/- 0.7 and 11.0 +/- 0.4 mmoles X kg-1 of wet wt in distal tubular cells. The intracellular sodium concentrations rose from 10.4 +/- 0.7 to 15.8 +/- 0.8, 19.1 +/- 0.8 to 24.1 +/- 0.7 and 14.1 +/- 0.5 to 16.2 +/- 0.6 mmoles X kg-1 of wet wt in distal tubular, proximal tubular and liver cells, respectively. This rise in cellular sodium was insufficient in any cell type to compensate for the loss of potassium. No significant differences were found in the cellular electrolyte concentrations of the various distal tubular cell types which are thought to be involved in either potassium reabsorption or secretion. The decrease in potassium concentrations in distal tubular cells by about 20% does not seem sufficient to explain the marked fall in urinary potassium excretion.

Magnesium treatment of diuretic-induced hyponatremia with a preliminary report of a new aldosterone-antagonist

Long-term diuretic treatment of patients with congestive heart failure is often complicated by hyponatremia and resistance to diuretic treatment, as well as by hypokalemia. Less widely recognized is the increase in intracellular sodium in the presence of hyponatremia, and loss of magnesium, caused by sustained diuretic therapy. Because the sodium pump, which maintains intracellular sodium and potassium against a concentration gradient, is dependent on optimal magnesium levels, we have investigated the influence of magnesium infusions on serum and skeletal muscle levels of sodium and potassium in congestive heart failure patients with electrolyte disturbances. Because aldosteronism, such as accompanies the disease and diuretic treatment, increases intracellular sodium, we have measured intracellular sodium and potassium in six patients given a new aldosterone antagonist (canrenone). It lowered the muscle sodium and raised the muscle potassium and magnesium, and slightly raised the serum sodium. The magnesium infusions, given to eight patients, significantly increased the serum sodium and lowered the muscle sodium levels, and normalized both serum and subnormal muscle potassium levels.

Effects of magnesium infusions in diuretic induced hyponatraemia

Eight hyponatraemic patients with severe congestive heart failure, long-term diuretic treatment, oedema, and increasing resistance to diuretic treatment, were studied with skeletal muscle biopsies and serum electrolytes before and after magnesium infusions. The infusions resulted in an increasing serum sodium level, a decrease in muscle sodium and chloride, and an increase in muscle potassium. The effect was probably mediated through the magnesium effect on membrane ATPase.

Morphologic alterations in the rat medullary collecting duct following potassium depletion

Freeze-fracture and thin-section electron microscopy and morphometry were used to characterize further the response of the rat medullary collecting duct to potassium depletion. In freeze-fracture replicas, principal cells and intercalated cells were identified based on the assumption that intercalated cells possess a high density of rod-shaped intramembrane particles in their luminal membranes. Potassium depletion caused an increase in the relative number of cells with a high density of rod-shaped particles from the control level of 22% to 31% after 2 weeks and to 36% after 4 weeks. The frequency of intercalated cells identified by thin-section criteria was, however, about 35% in controls and unchanged by potassium depletion. This suggests that intercalated cells can have two types of membrane morphology. In potassium depletion, all intercalated cells display a high density of rod-shaped particles in their luminal membranes. In addition, the luminal membrane area of intercalated cells increased more than threefold, and the density of their rod-shaped particles increased by 21%. These observations suggest that the intercalated cell and its rod-shaped particle may be involved with the potassium reabsorption that occurs in this nephron segment with potassium depletion.

Ventricular extrasystoles and intracellular electrolytes before and after potassium and magnesium infusions in patients on diuretic treatment

Thirty-four patients suspected of being magnesium deficient were given intravenous infusions of potassium and magnesium. The muscle contents of sodium, potassium, magnesium, and chloride were determined by atomic absorption spectrophotometry on skeletal muscle samples obtained by percutaneous biopsies. The frequency of ventricular etopic beats (VEBs) was assessed from a 3-hour ECG tape recording before the infusions and after the completion of each infusion. The potassium infusions did not result in any changes in the cellular potassium content, nor in the frequency of VEBs. After the magnesium infusions, however, a significant increase was noted in the cellular potassium content and likewise a significant decrease in the frequency of VEBs. This emphasizes the importance of magnesium in potassium metabolism.

Potassium and intracellular pH

Recent work has clarified some of the complex interrelationships between cell pH and potassium. These studies have been limited by the techniques available for accurately measuring cell pH. At present it is obvious that intracellular pH is a major regulator of the cellular potassium concentration, but the precise relationship between these two is still uncertain. It has become increasingly clear, however, that no simple relationship exists between the intracellular to extracellular hydrogen ion and potassium ion ratios. Many experiments do demonstrate that the extracellular metabolic alkalosis of potassium depletion is accompanied by a decrease in skeletal muscle pH in rat, rabbit, and probably dog. The response of cardiac and renal tubular cell pH to potassium depletion is less clear, although most evidence indicates that there is also a reduction in the pH of these tissues. This effect on cell pH appears to be independent of chloride. By contrast, hyperkalemia seems to raise muscle cell pH at the same time it induces an extracellular metabolic acidosis. The metabolic and physiologic consequences of potassium-induced alterations in cell pH have yet to be fully elucidated.

Hypokalemic myopathy during treatment with diuretics

Two male patients with severe reversible muscle weakness and excessive potassium deficiency associated with alkalosis during treatment with diuretics are presented. The case reports are further illustrated by the morphologic changes as seen in light and electron microscopic examination of muscle biopsies. Hypokalemia and muscle dysfunction are discussed in relation to other investigations of altered potassium metabolism and myopathy during treatment with certain diuretics.

Intracellular pH: measurement, control, and metabolic interrelationships

Recent work in the field of cell pH has been characterized by many developments in techniques of measurement, by increasing knowledge of the mechanism of control of cell pH, and by progress in the establishment of relationships between cell pHi and certain areas of intermediary metabolism. Though the weight of evidence is much in favor of control cell pH by active transport of H+, the situation remains somewhat unsatisfactory due to lack of a completely adequate explanation of the work of Carter's group. The heterogeneity of cell pH raises problems in the intrepretation of hydrogen ion equilibria across cell membranes and serious difficulties in correlating changes with alterations in metabolism. To put this into perspective, however, the later difficulties are no greater than many experienced with cell constituents other than hydrogen ions.90 As in other fields, knowledge must advance by making the best of the currently available methods until such time as better techniques become available.

Effect of volume expansion on renal citrate and ammonia metabolism in KCl-deficient rats

When rats with desoxycorticosterone acetate (DOCA)-induced potassium chloride deficiency are given sodium chloride there is simultaneously a partial correction of metabolic alkalosis and a marked reduction in urinary citrate excretion and renal citrate content. To examine DOCA's role in this phenomenon and to determine how sodium chloride alters renal metabolism, rats were made KC1 deficient using furosemide and a KC1-deficient diet. Renal citrate and ammonia metabolism were then studied after chronic oral sodium chloride administration or acute volume expansion with isotonic mannitol. Although both maneuvers partially corrected metabolic alkalosis, sodium chloride raised serum chloride concentration while mannitol significantly decreased it. Urinary citrate excretion decreased to 10% of control in rats given NaCl and to 50% of control in rats infused with mannitol. The filtered load of citrate was constant or increased indicating increased tubular citrate reabsorption. Renal cortical citrate content also decreased approximately 50%. Renal cortical slices from KCl-deficient rats incubated in low or normal chloride media produced equal amounts of 14CO2 from (1, 5-14C) citrate. In addition, urinary ammonia excretion increased by over 300% in both groups. This occurred in the mannitol group despite increased urinary pH and flow rate indicating a rise in renal ammonia production. It seems that neither DOCA nor an increase in serum chloride concentration explains the experimental results. Rather, it appears that volume expansion is responsible for increased renal tubular citrate reabsorption and renal ammonia production. As these renal metabolic responses ordinarily occur in response to acidosis, the data are consistent with the hypothesis that volume expansion reduces renal cell pH in 3KCl-deficient rats.