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Wuttiputhanun T, Townamchai N, Eiam‐Ong S, Takkavatakarn K. Metabolic alkalosis masked presentation of diabetic ketoacidosis: A case report. Clin Case Rep 2023; 11:e8250. [PMID: 38033688 PMCID: PMC10682229 DOI: 10.1002/ccr3.8250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023] Open
Abstract
Managing mixed acid-base disorders can be diagnostically challenging, particularly when metabolic acidosis and metabolic alkalosis occur simultaneously. When dealing with metabolic alkalosis, a comprehensive approach involves taking a detailed medical history, assessing volume status, and performing urine chloride analysis. Routine calculation of the anion gap is important to identify masked wide anion gap metabolic acidosis. We report a case of a 32-year-old female with type 1 diabetes mellitus, presented with intractable vomiting for 2 days with hyperglycemia, hypokalemia, and metabolic alkalosis, along with a wide anion gap. She was diagnosed with "diabetic ketoalkalosis" due to diabetic ketoacidosis combined with vomiting-induced metabolic alkalosis. She became clinically stable after resuscitation with normal saline, intravenous potassium, and intravenous insulin.
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Affiliation(s)
- Thunyatorn Wuttiputhanun
- Division of Nephrology, Department of MedicineKing Chulalongkorn Memorial Hospital and Chulalongkorn UniversityBangkokThailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of MedicineKing Chulalongkorn Memorial Hospital and Chulalongkorn UniversityBangkokThailand
| | - Somchai Eiam‐Ong
- Division of Nephrology, Department of MedicineKing Chulalongkorn Memorial Hospital and Chulalongkorn UniversityBangkokThailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of MedicineKing Chulalongkorn Memorial Hospital and Chulalongkorn UniversityBangkokThailand
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2
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Ryuge A, Nagamine S, Saito M, Matsumoto N, Asano M. Hypernatremic chloride-depletion metabolic alkalosis successfully treated with high cation-gap amino acids: a case report. CEN Case Rep 2023:10.1007/s13730-023-00837-z. [PMID: 37991678 DOI: 10.1007/s13730-023-00837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023] Open
Abstract
Normal saline (NS) is recommended for the treatment of chloride-depletion alkalosis (CDA). However, its use in patients with drinking water restrictions or fluid volume deficiencies may lead to hypernatremia. We report the case of a 42-year-old Japanese man with ileus due to sigmoidal volvulus, who presented with CDA. After endoscopic decompression, NS was administered to treat the CDA. Despite the administration of NS, CDA persisted and hypernatremia developed. The infusion was then changed to high cation-gap amino acids (HCG-AA), which improved both metabolic alkalosis and hypernatremia. Thus, HCG-AA may be useful for the treatment of hypernatremia in patients with CDA.
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Affiliation(s)
- Akihiro Ryuge
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan.
| | - Shogo Nagamine
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
| | - Masashi Saito
- Department of Gastroenterology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naoki Matsumoto
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
| | - Marina Asano
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan
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3
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Sanghavi SF, Swenson ER. Arterial Blood Gases and Acid-Base Regulation. Semin Respir Crit Care Med 2023; 44:612-626. [PMID: 37369215 DOI: 10.1055/s-0043-1770341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Disorders of acid-base status are common in the critically ill and prompt recognition is central to clinical decision making. The bicarbonate/carbon dioxide buffer system plays a pivotal role in maintaining acid-base homeostasis, and measurements of pH, PCO2, and HCO3 - are routinely used in the estimation of metabolic and respiratory disturbance severity. Hypoventilation and hyperventilation cause primary respiratory acidosis and primary respiratory alkalosis, respectively. Metabolic acidosis and metabolic alkalosis have numerous origins, that include alterations in acid or base intake, body fluid losses, abnormalities of intermediary metabolism, and renal, hepatic, and gastrointestinal dysfunction. The concept of the anion gap is used to categorize metabolic acidoses, and urine chloride excretion helps define metabolic alkaloses. Both the lungs and kidneys employ compensatory mechanisms to minimize changes in pH caused by various physiologic and disease disturbances. Treatment of acid-base disorders should focus primarily on correcting the underlying cause and the hemodynamic and electrolyte derangements that ensue. Specific therapies under certain conditions include renal replacement therapy, mechanical ventilation, respiratory stimulants or depressants, and inhibition of specific enzymes in intermediary metabolism disorders.
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Affiliation(s)
- Sarah F Sanghavi
- Division of Nephrology, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
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4
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Suh SH, Oh TR, Choi HS, Kim CS, Bae EH, Ma SK, Oh KH, Yoo TH, Chae DW, Kim SW. Association between urinary chloride excretion and progression of coronary artery calcification in patients with nondialysis chronic kidney disease: results from the KNOW-CKD study. Kidney Res Clin Pract 2023; 42:251-261. [PMID: 36908202 PMCID: PMC10085721 DOI: 10.23876/j.krcp.22.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Urine chloride has recently been suggested as a biomarker of renal tubule function in patients with nondialysis chronic kidney disease (CKD), as low urinary chloride concentration is associated with an increased risk of CKD progression. We investigate the association between urinary chloride excretion and the progression of coronary artery calcification (CAC). METHODS A total of 1,065 patients with nondialysis CKD were divided into tertiles by spot urine chloride-to-creatinine ratios. The 1st, 2nd, and 3rd tertiles were defined as low, moderate, and high urinary chloride excretion, respectively. The study outcome was CAC progression, which was defined as an increase in coronary artery calcium score of more than 200 Agatston units during the 4-year follow-up period. RESULTS Compared to moderate urinary chloride excretion, high urinary chloride excretion was associated with decreased risk of CAC progression (adjusted odds ratio, 0.379; 95% confidence interval, 0.190-0.757), whereas low urinary chloride excretion was not associated with risk of CAC progression. Restricted cubic spine depicted an inverted J-shaped curve, with a significant reduction in the risk of CAC progression in subjects with high spot urine chloride-to-creatinine ratios. CONCLUSION High urinary chloride excretion is associated with decreased risk of CAC progression in patients with nondialysis CKD.
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Affiliation(s)
- Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Tae Ryom Oh
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine and Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - on behalf of the Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) Investigators
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine and Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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5
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Wray SR, Patel PP, Jackson CD. Mind the gap: A case of unexplained elevated anion gap without concomitant metabolic acidosis. J Natl Med Assoc 2023; 115:77-80. [PMID: 36535807 DOI: 10.1016/j.jnma.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/16/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
Hypertriglyceridemia causing unexplained hypobicarbotinemia and elevated anion gap is rare. We report the case of a 33-year-old woman who presented with an unexplained high anion gap after a subacute gastrointestinal illness. An arterial blood gas showed a normal bicarbonate level, and a lipid panel resulted in a triglyceride level too high to read, establishing the diagnosis. Treatment included using triglyceride-lowering agents with normalization in the patient's serum bicarbonate levels.
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Affiliation(s)
- Samantha R Wray
- Department of Medicine, Division of General Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Puja P Patel
- Department of Medicine, Division of Rheumatology, University of Tennessee Health Science Center, Memphis, TN
| | - Christopher D Jackson
- Department of Medicine, Division of General Internal Medicine, University of Tennessee Health Science Center, Memphis, TN.
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Gamliel A, Shaul D, Gomori JM, Katz‐Brull R. Signal enhancement of hyperpolarized 15 N sites in solution-increase in solid-state polarization at 3.35 T and prolongation of relaxation in deuterated water mixtures. NMR IN BIOMEDICINE 2022; 35:e4787. [PMID: 35704397 PMCID: PMC9787933 DOI: 10.1002/nbm.4787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
Hyperpolarized 15 N sites have been found to be promising for generating long-lived hyperpolarized states in solution, and present a promising approach for utilizing dissolution-dynamic nuclear polarization (dDNP)-driven hyperpolarized MRI for imaging in biology and medicine. Specifically, 15 N sites with directly bound protons were shown to be useful when dissolved in D2 O. The purpose of the current study was to further characterize and increase the visibility of such 15 N sites in solutions that mimic an intravenous injection during the first cardiac pass in terms of their H2 O:D2 O composition. The T1 values of hyperpolarized 15 N in [15 N2 ]urea and [15 N]NH4 Cl demonstrated similar dependences on the H2 O:D2 O composition of the solution, with a T1 of about 140 s in 100% D2 O, about twofold shortening in 90% and 80% D2 O, and about threefold shortening in 50% D2 O. [13 C]urea was found to be a useful solid-state 13 C marker for qualitative monitoring of the 15 N polarization process in a commercial pre-clinical dDNP device. Adding trace amounts of Gd3+ to the polarization formulation led to higher solid-state polarization of [13 C]urea and to higher polarization levels of [15 N2 ]urea in solution.
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Affiliation(s)
- Ayelet Gamliel
- Department of Radiology, Hadassah Medical Organization and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- The Wohl Institute for Translational MedicineHadassah Medical OrganizationJerusalemIsrael
| | - David Shaul
- Department of Radiology, Hadassah Medical Organization and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- The Wohl Institute for Translational MedicineHadassah Medical OrganizationJerusalemIsrael
| | - J. Moshe Gomori
- Department of Radiology, Hadassah Medical Organization and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Rachel Katz‐Brull
- Department of Radiology, Hadassah Medical Organization and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- The Wohl Institute for Translational MedicineHadassah Medical OrganizationJerusalemIsrael
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7
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Buzakuk B, van der Voort J. Metabolic mayhem. The advantage of keeping your nose both in the books and in the nappy! Arch Dis Child Educ Pract Ed 2022; 107:150-155. [PMID: 34131008 DOI: 10.1136/archdischild-2019-318477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/21/2021] [Indexed: 11/03/2022]
Abstract
This case presentation takes you on a journey of diagnostic hurdles, covering a common neonatal presentation: abdominal distention with failure to pass meconium, followed by a presentation in infancy with metabolic, renal and electrolyte abnormalities. The article provides a systematic approach to the different clinical problems, allowing interpretation of results, making differential diagnoses and deciding on investigations and management.
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Affiliation(s)
- Buthaina Buzakuk
- Paediatrics and Paediatric Gastroenterology, Swansea Bay University Health Board, Swansea, Neath Port Talbot, UK
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8
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Lee MS, Shin TG, Kim WY, Jo YH, Hwang YJ, Choi SH, Lim T, Han KS, Shin J, Suh GJ, Kim KS, Kang GH. Hypochloraemia is associated with 28-day mortality in patients with septic shock: a retrospective analysis of a multicentre prospective registry. Emerg Med J 2020; 38:423-429. [PMID: 32883752 DOI: 10.1136/emermed-2019-209239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Hyperchloraemia is associated with poor clinical outcomes in sepsis patients; however, this association is not well studied for hypochloraemia. We investigated the prevalence of chloride imbalance and the association between hypochloraemia and 28-day mortality in ED patients with septic shock. METHODS A retrospective analysis of data from 11 multicentre EDs in the Republic of Korea prospectively collected from October 2015 to April 2018 was performed. Initial chloride levels were categorised as hypochloraemia, normochloraemia and hyperchloraemia, according to sodium chloride difference adjusted criteria. The primary outcome was 28-day mortality. A multivariate logistic regression model adjusting for age, sex, comorbidities, acid-base state, sepsis-related organ failure assessment (SOFA) score, lactate and albumin level was used to test the association between the three chloride categories and 28-day mortality. RESULTS Among 2037 enrolled patients, 394 (19.3%), 1582 (77.7%) and 61 (3.0%) patients had hypochloraemia, normochloraemia and hyperchloraemia, respectively. The unadjusted 28-day mortality rate in patients with hypochloraemia was 27.4% (95% CI, 23.1% to 32.1%), which was higher than in patients with normochloraemia (19.7%; 95% CI, 17.8% to 21.8%). Hypochloraemia was associated with an increase in the risk of 28-day mortality (adjusted OR (aOR), 1.36, 95% CI, 1.00 to 1.83) after adjusting for confounders. However, hyperchloraemia was not associated with 28-day mortality (aOR 1.35, 95% CI, 0.82 to 2.24). CONCLUSION Hypochloraemia was more frequently observed than hyperchloraemia in ED patients with septic shock and it was associated with 28-day mortality.
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Affiliation(s)
- Min Sung Lee
- Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae Gun Shin
- Emergency Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Won Young Kim
- Emergency Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - You Hwan Jo
- Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yoon Jung Hwang
- Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hyuk Choi
- Emergency Medicine, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Taeho Lim
- Emergency Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Kap Su Han
- Emergency Medicine, College of Medicine Korea University, Seoul, Republic of Korea
| | - JongHwan Shin
- Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Gil Joon Suh
- Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Su Kim
- Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gu Hyun Kang
- Emergency medicine, Hallym University College of Medicine, Seoul, Republic of Korea
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9
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Abstract
Metabolic alkalosis defined by the increase of both plasma HCO3- level (>26 mmol/L) and blood arterial pH (>7.43) is quite frequent and usually accompanied by hypokalemia. Its pathogenesis requires both the generation of alkalosis and its maintenance. Generation may be due to excessive hydrogen ion loss by the gastrointestinal tract (e.g. vomiting) or by the kidney (e.g. use of loop diuretics) or may be due to exogenous base gain. Maintenance reflects the inability of the kidney to excrete the excess of bicarbonate because of hypovolemia, chloride depletion, hypokalemia, hyperaldosteronism, renal failure or a combination of these factors. The evaluation of volemic status and measurement of urinary Cl- and plasma levels of renin and aldosterone are crucial to identify the cause(s) of metabolic alkalosis. The cornerstone of treatment is the correction of existing depletions and the prevention of further losses. In vomiting-induced chloride depletion alkalosis, infusion of potassium chloride restores the excretion of bicarbonate by the kidney.
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Affiliation(s)
- Valentine Gillion
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Michel Jadoul
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Olivier Devuyst
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Jean-Michel Pochet
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
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10
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Palmer BF, Clegg DJ. The Use of Selected Urine Chemistries in the Diagnosis of Kidney Disorders. Clin J Am Soc Nephrol 2019; 14:306-316. [PMID: 30626576 PMCID: PMC6390907 DOI: 10.2215/cjn.10330818] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary chemistries vary widely in both health and disease and are affected by diet, volume status, medications, and disease states. When properly examined, these tests provide important insight into the mechanism and therapy of various clinical disorders that are first detected by abnormalities in plasma chemistries. These tests cannot be interpreted in isolation, but instead require knowledge of key clinical information, such as medications, physical examination, and plasma chemistries, to include kidney function. When used appropriately and with knowledge of limitations, urine chemistries can provide important insight into the pathophysiology and treatment of a wide variety of disorders.
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Affiliation(s)
- Biff F Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Deborah Joy Clegg
- Department of Internal Medicine, University of California, Los Angeles School of Medicine, Los Angeles, California
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11
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Bushinsky DA. Tolerance to Sodium in Patients With CKD-Induced Metabolic Acidosis: Does the Accompanying Anion Matter? Am J Kidney Dis 2018; 73:858-865. [PMID: 30518477 DOI: 10.1053/j.ajkd.2018.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/07/2018] [Indexed: 11/11/2022]
Abstract
Patients with chronic kidney disease (CKD) continue to produce endogenous acids but have a reduction in net acid excretion, resulting in a primary decrease in serum bicarbonate concentration, which is termed chronic metabolic acidosis. Recent prospective studies, along with retrospective cohort analyses, demonstrate a higher risk for CKD progression with untreated metabolic acidosis. To normalize serum bicarbonate levels, acidemic patients are often treated with sodium bicarbonate (NaHCO3) or sodium citrate, which have been shown to slow the progression of CKD. However, studies using this approach have routinely excluded patients with common sodium-sensitive comorbid conditions, such as poorly controlled hypertension, congestive heart failure, volume overload, or edema. This article examines the effect of the anion that accompanies sodium delivered with these therapies. Do the negative effects on blood pressure (BP) and sodium retention, as measured by an increase in edema, weight gain, and congestive heart failure, observed with oral administration of sodium chloride (NaCl) differ when a similar amount of sodium is given with bicarbonate or citrate in this patient population? A review of the literature suggests that NaHCO3 does not increase BP or sodium retention when administered to patients with CKD during a concurrent severe NaCl dietary restriction (∼10 mEq/d). However, this degree of NaCl restriction is feasible only under strict control in clinical research environments. In contrast, when NaHCO3 is given to patients without severe dietary NaCl restriction, there is an increase in BP and sodium retention. Thus, unless patients with CKD can tolerate a diet virtually devoid of NaCl, additional sodium, regardless of the accompanying anion, appears to increase BP and sodium retention.
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Affiliation(s)
- David A Bushinsky
- University of Rochester School of Medicine and Dentistry, Rochester, NY.
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12
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Nissen M, Cernaianu G, Thränhardt R, Vahdad MR, Barenberg K, Tröbs RB. Does metabolic alkalosis influence cerebral oxygenation in infantile hypertrophic pyloric stenosis? J Surg Res 2017; 212:229-237. [PMID: 28550912 DOI: 10.1016/j.jss.2017.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/30/2016] [Accepted: 01/19/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This pilot study focuses on regional tissue oxygenation (rSO2) in patients with infantile hypertrophic pyloric stenosis in a perioperative setting. To investigate the influence of enhanced metabolic alkalosis (MA) on cerebral (c-rSO2) and renal (r-rSO2) tissue oxygenation, two-site near-infrared spectroscopy (NIRS) technology was applied. MATERIALS AND METHODS Perioperative c-rSO2, r-rSO2, capillary blood gases, and electrolytes from 12 infants were retrospectively compared before and after correction of MA at admission (T1), before surgery (T2), and after surgery (T3). RESULTS Correction of MA was associated with an alteration of cerebral oxygenation without affecting renal oxygenation. When compared to T1, 5-min mean (± standard deviation) c-rSO2 increased after correction of MA at T2 (72.74 ± 4.60% versus 77.89 ± 5.84%; P = 0.058), reaching significance at T3 (80.79 ± 5.29%; P = 0.003). Furthermore, relative 30-min c-rSO2 values at first 3 h of metabolic compensation were significantly lowered compared with postsurgical states at 16 and 24 h. Cerebral oxygenation was positively correlated with levels of sodium (r = 0.37; P = 0.03) and inversely correlated with levels of bicarbonate (r = -0.34; P = 0.05) and base excess (r = -0.36; P = 0.04). Analysis of preoperative and postoperative cerebral and renal hypoxic burden yielded no differences. However, a negative correlation (r = -0.40; P = 0.03) regarding hematocrite and mean r-rSO2, indirectly indicative of an increased renal blood flow under hemodilution, was obtained. CONCLUSIONS NIRS seems suitable for the detection of a transiently impaired cerebral oxygenation under state of pronounced MA in infants with infantile hypertrophic pyloric stenosis. Correction of MA led to normalization of c-rSO2. NIRS technology constitutes a promising tool for optimizing perioperative management, especially in the context of a possible diminished neurodevelopmental outcome after pyloromyotomy.
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Affiliation(s)
- Matthias Nissen
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany.
| | - Grigore Cernaianu
- Department of Pediatrics and Adolescent Medicine, Pediatric Surgery, University of Cologne, Cologne, Germany
| | - Rene Thränhardt
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Mohammad R Vahdad
- Department of Pediatric Surgery, University Hospital Giessen/Marburg, Marburg, Germany
| | - Karin Barenberg
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Ralf-Bodo Tröbs
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
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13
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Kreü S, Jazrawi A, Miller J, Baigi A, Chew M. Alkalosis in Critically Ill Patients with Severe Sepsis and Septic Shock. PLoS One 2017; 12:e0168563. [PMID: 28045915 PMCID: PMC5207677 DOI: 10.1371/journal.pone.0168563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 12/03/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Although metabolic alkalosis is a common occurrence in intensive care units (ICUs), no study has evaluated its prevalence or outcomes in patients with severe sepsis or septic shock. METHODS This is a retrospective cohort study of critically ill patients suffering from severe sepsis and septic shock admitted to the ICUs of Halmstad and Varberg County hospitals. From 910 patient records, 627 patients met the inclusion criteria. We investigated the relationship between metabolic alkalosis and mortality. Further, we studied the relationship between metabolic alkalosis and ICU length of stay (LOS). RESULTS Metabolic alkalosis was associated with decreased 30-day and 12-month mortalities. This effect was however lost when a multivariate analysis was conducted, correcting for age, gender, pH on admission, base excess (BE) on admission, Simplified Acute Physiology Score III (SAPS III) and acute kidney injury (AKI). We then analyzed for any dose-response effect between the severity of metabolic alkalosis and mortality and found no relationship. Bivariate analysis showed that metabolic alkalosis had a significant effect on the length of ICU stay. When adjusting for age, sex, pH at admission, BE at admission, SAPS III and AKI in a multivariate analysis, metabolic alkalosis significantly contributed to prolonged ICU length of stay. In two separate sensitivity analyses pure metabolic alkalosis and late metabolic alkalosis (time of onset >48 hours) were the only significant predictor of increased ICU length of stay. CONCLUSION Metabolic alkalosis did not have any effect on 30-day and 12-month mortalities after adjusting for age, sex, SAPS III-score, pH and BE on admission and AKI in a multivariate analysis. The presence of metabolic alkalosis was independently associated with an increased ICU length of stay.
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Affiliation(s)
- Simon Kreü
- Institute for Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
- * E-mail:
| | - Allan Jazrawi
- Institute for Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of General Surgery, Västmanland County Hospital, Västerås, Sweden
| | - Jan Miller
- Institute for Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Amir Baigi
- Institute of Medicine, General Medicine and Public Health, Gothenburg University, Gothenburg, Sweden
| | - Michelle Chew
- Institute for Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Linköping University Hospital, Linköping, Sweden
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14
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Koh C, Minns A, Rosen P. A Practical Approach to the Ethanol-Intoxicated Patient in the Emergency Department. J Emerg Med 2016; 51:463-464. [PMID: 27697198 DOI: 10.1016/j.jemermed.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/10/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Cynthia Koh
- Division of Medical Toxicology, Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Alicia Minns
- Division of Medical Toxicology, Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Peter Rosen
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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15
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Serum Bicarbonate in Acute Heart Failure: Relationship to Treatment Strategies and Clinical Outcomes. J Card Fail 2016; 22:738-42. [PMID: 26777758 DOI: 10.1016/j.cardfail.2016.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/22/2015] [Accepted: 01/07/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Though commonly noted in clinical practice, it is unknown if decongestion in acute heart failure (AHF) results in increased serum bicarbonate. METHODS AND RESULTS For 678 AHF patients in the DOSE-AHF, CARRESS-HF, and ROSE-AHF trials, we assessed change in bicarbonate (baseline to 72-96 hours) according to decongestion strategy, and the relationship between bicarbonate change and protocol-defined decongestion. Median baseline bicarbonate was 28 mEq/L. Patients with baseline bicarbonate ≥28 mEq/L had lower ejection fraction, worse renal function and higher N-terminal pro-B-type natriuretic peptide than those with baseline bicarbonate <28 mEq/L. There were no differences in bicarbonate change between treatment groups in DOSE-AHF or ROSE-AHF (all P > .1). In CARRESS-HF, bicarbonate increased with pharmacologic care but decreased with ultrafiltration (median +3.3 vs -0.9 mEq/L, respectively; P < .001). Bicarbonate change was not associated with successful decongestion (P > .2 for all trials). CONCLUSIONS In AHF, serum bicarbonate is most commonly elevated in patients with more severe heart failure. Despite being used in clinical practice as an indicator for decongestion, change in serum bicarbonate was not associated with significant decongestion.
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Drug-induced acid-base disorders. Pediatr Nephrol 2015; 30:1407-23. [PMID: 25370778 DOI: 10.1007/s00467-014-2958-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
The incidence of acid-base disorders (ABDs) is high, especially in hospitalized patients. ABDs are often indicators for severe systemic disorders. In everyday clinical practice, analysis of ABDs must be performed in a standardized manner. Highly sensitive diagnostic tools to distinguish the various ABDs include the anion gap and the serum osmolar gap. Drug-induced ABDs can be classified into five different categories in terms of their pathophysiology: (1) metabolic acidosis caused by acid overload, which may occur through accumulation of acids by endogenous (e.g., lactic acidosis by biguanides, propofol-related syndrome) or exogenous (e.g., glycol-dependant drugs, such as diazepam or salicylates) mechanisms or by decreased renal acid excretion (e.g., distal renal tubular acidosis by amphotericin B, nonsteroidal anti-inflammatory drugs, vitamin D); (2) base loss: proximal renal tubular acidosis by drugs (e.g., ifosfamide, aminoglycosides, carbonic anhydrase inhibitors, antiretrovirals, oxaliplatin or cisplatin) in the context of Fanconi syndrome; (3) alkalosis resulting from acid and/or chloride loss by renal (e.g., diuretics, penicillins, aminoglycosides) or extrarenal (e.g., laxative drugs) mechanisms; (4) exogenous bicarbonate loads: milk-alkali syndrome, overshoot alkalosis after bicarbonate therapy or citrate administration; and (5) respiratory acidosis or alkalosis resulting from drug-induced depression of the respiratory center or neuromuscular impairment (e.g., anesthetics, sedatives) or hyperventilation (e.g., salicylates, epinephrine, nicotine).
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Acetazolamide for the Management of Chronic Metabolic Alkalosis in Neonates and Infants. Am J Ther 2014; 21:477-81. [DOI: 10.1097/mjt.0b013e31825e792c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Marston N, Kehl D, Copp J, Nourbakhsh N, Rifkin DE. Alkalotics anonymous: severe metabolic alkalosis. Am J Med 2014; 127:25-7. [PMID: 24268303 DOI: 10.1016/j.amjmed.2013.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 09/19/2013] [Accepted: 09/20/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Nicholas Marston
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Devin Kehl
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Jonathan Copp
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Noureddin Nourbakhsh
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Dena E Rifkin
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA; Veterans Affairs San Diego Healthcare System, San Diego, CA.
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Al-Abri SA, Olson KR. Baking soda can settle the stomach but upset the heart: case files of the Medical Toxicology Fellowship at the University of California, San Francisco. J Med Toxicol 2013; 9:255-8. [PMID: 23591957 PMCID: PMC3770998 DOI: 10.1007/s13181-013-0300-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Suad A. Al-Abri
- California Poison Control System, San Francisco Division, University of California, San Francisco, UCSF Box 1369, San Francisco, CA 94143-1369 USA
| | - Kent R. Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, UCSF Box 1369, San Francisco, CA 94143-1369 USA
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Palmer BF, Glassock RJ, Bleyer AJ. American Society of Nephrology Quiz and Questionnaire 2012: electrolytes. Clin J Am Soc Nephrol 2013; 8:1048-53. [PMID: 23580784 DOI: 10.2215/cjn.00460113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Presentation of the Nephrology Quiz and Questionnaire has become an annual tradition at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They can also compare their answers in real time, using audience response devices, with the answers of program directors of nephrology training programs in the United States acquired through an Internet-based questionnaire. Topics presented here include fluid and electrolyte disorders, transplantation, and ESRD and dialysis. Cases representing each of these categories along with single best answer questions were prepared by a panel of experts (B.F.P. and Drs. Fervenza, Brennan, and Mehrotra, respectively). The correct and incorrect answers then were briefly discussed after the audience responses, and the results of the questionnaire were displayed. This article tries to recapitulate the session and reproduce its educational value for a larger audience--the readers of CJASN.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA.
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Mathew JT, Bio LL. Injectable ammonium chloride used enterally for the treatment of persistent metabolic alkalosis in three pediatric patients. J Pediatr Pharmacol Ther 2012; 17:98-103. [PMID: 23118664 DOI: 10.5863/1551-6776-17.1.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Enteral administration of injectable ammonium chloride may offer an effective method for the treatment of persistent metabolic alkalosis, without the adverse effects associated with the intravenous route. This case series describes 3 pediatric patients who received ammonium chloride enterally for the treatment of persistent metabolic alkalosis. The patients were a 2-month-old female infant, a 6-week-old male infant, and a 3-year-old male toddler. Four to 18 doses of ammonium chloride were administered enterally (range, 3-144 mEq/dose). Two of the 3 patients achieved resolution of metabolic alkalosis with ammonium chloride, while 1 patient's condition was refractory to treatment. Resolution of metabolic alkalosis occurred at 4 and 8 days, which required a total weight-based dose of 10.7 mEq/kg and 18 mEq/kg, respectively. No adverse effects were recorded. The use of ammonium chloride injection administered enterally was a safe and effective option in 2 of the 3 pediatric patients with persistent metabolic alkalosis.
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Affiliation(s)
- Jennie T Mathew
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
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Heming N, Urien S, Faisy C. Acetazolamide: a second wind for a respiratory stimulant in the intensive care unit? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:318. [PMID: 22866939 PMCID: PMC3580678 DOI: 10.1186/cc11323] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are affected by episodes of respiratory exacerbations, some of which can be severe and may necessitate respiratory support. Prolonged invasive mechanical ventilation is associated with increased mortality rates. Persistent failure to discontinue invasive mechanical ventilation is a major issue in patients with COPD. Pure or mixed metabolic alkalosis is a common finding in the intensive care unit (ICU) and is associated with a worse outcome. In patients with COPD, the condition is called post-hypercapnic alkalosis and is a complication of mechanical ventilation. Reversal of metabolic alkalosis may facilitate weaning from mechanical ventilation of patients with COPD. Acetazolamide, a non-specific carbonic anhydrase inhibitor, is one of the drugs employed in the ICU to reverse metabolic alkalosis. The drug is relatively safe, undesirable effects being rare. The compartmentalization of the different isoforms of the carbonic anhydrase enzyme may, in part, explain the lack of evidence of the efficacy of acetazolamide as a respiratory stimulant. Recent findings suggest that the usually employed doses of acetazolamide in the ICU may be insufficient to significantly improve respiratory parameters in mechanically ventilated patients with COPD. Randomized controlled trials using adequate doses of acetazolamide are required to address this issue.
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Palmer BF. Evaluation and treatment of respiratory alkalosis. Am J Kidney Dis 2012; 60:834-8. [PMID: 22871240 DOI: 10.1053/j.ajkd.2012.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/20/2012] [Indexed: 11/11/2022]
Abstract
Respiratory alkalosis is the most frequent acid-base disturbance encountered in clinical practice. This is particularly true in critically ill patients, for whom the degree of hypocapnia directly correlates with adverse outcomes. Although this acid-base disturbance often is considered benign, evidence suggests that the alkalemia of primary hypocapnia can cause clinically significant decreases in tissue oxygen delivery. Mild respiratory alkalosis often serves as a marker of an underlying disease and may not require therapeutic intervention. In contrast, severe respiratory alkalosis should be approached with a sense of urgency and be aggressively corrected.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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Tani M, Morimatsu H, Takatsu F, Morita K. The incidence and prognostic value of hypochloremia in critically ill patients. ScientificWorldJournal 2012; 2012:474185. [PMID: 22701359 PMCID: PMC3373177 DOI: 10.1100/2012/474185] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 03/25/2012] [Indexed: 11/17/2022] Open
Abstract
Little is known on the clinical effects of chloride on critically ill patients. We conducted this retrospective, observational study in 488 critically ill patients to investigate the incidence of chloride abnormalities, effects of hypochloremia in acid-base disorders, and association between chloride and clinical outcome. The study involved retrieval of arterial blood gas analyses, biochemical and demographical data from electrical records as well as quantitative acid-base analyses. For statistical analysis, the patients were stratified into three groups according to their chloride level (normal range: 98–106 mEq/L). The distribution of chloride levels was hyperchloremia 16.6%, normochloremia 74.6%, and hypochloremia 8.8%. The hypochloremic group was significantly alkalemic (P < 0.0001) and has significantly higher apparent strong ion difference (SIDa) (P < 0.0001) compared to the two other groups. The hypochloremic group had significantly longer stays in the ICU and hospital (P < 0.0001) with higher mortality (P < 0.0001). However, multiple regression analysis showed that chloride was not an independent factor of poorer outcome. In conclusion, the acid-base characteristics of the hypochloremic patients were alkalemia coexisting with higher SIDa. And although it was not an independent prognostic factor, hypochloremia was related to poorer outcome in critically ill settings.
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Affiliation(s)
- Makiko Tani
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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Yi JH, Han SW, Song JS, Kim HJ. Metabolic Alkalosis From Unsuspected Ingestion: Use of Urine pH and Anion Gap. Am J Kidney Dis 2012; 59:577-81. [DOI: 10.1053/j.ajkd.2011.11.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 11/28/2011] [Indexed: 11/11/2022]
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Abstract
Diuretics are commonly used therapeutic agents that act to inhibit sodium transport systems along the length of the renal tubule. The most effective diuretics are inhibitors of sodium chloride transport in the thick ascending limb of Henle. Loop diuretics mobilize large amounts of sodium chloride and water and produce a copious diuresis with a sharp reduction of extracellular fluid volume. As the site of action of diuretics moves downstream (thiazide and potassium-sparing diuretics), their effectiveness declines because the transport systems they inhibit have low transport capacity. Depending on the site of action diuretics can influence the renal handling of electrolyte-free water, calcium, potassium, protons, sodium bicarbonate, and uric acid. As a result, electrolyte and acid-base disorders commonly accompany diuretic use. Glucose and lipid abnormalities also can occur, particularly with the use of thiazide diuretics. This review focuses on the biochemical complications associated with the use of diuretics. The development of these complications can be minimized with careful monitoring, dosage adjustment, and replacement of electrolyte losses.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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Palmer BF. A Physiologic-Based Approach to the Evaluation of a Patient With Hypokalemia. Am J Kidney Dis 2010; 56:1184-90. [DOI: 10.1053/j.ajkd.2010.07.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 07/07/2010] [Indexed: 11/11/2022]
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Dos Santos PM, Freitas FP, Mendes J, Tararthuch AL, Fernandez R. Differential regulation of H+-ATPases in MDCK-C11 cells by aldosterone and vasopressin. Can J Physiol Pharmacol 2009; 87:653-65. [DOI: 10.1139/y09-057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of the present work was to characterize the biochemical activity of the proton pumps present in the C11 clone of Madin–Darby canine kidney (MDCK) cells, akin to intercalated cells of the collecting duct, as well as to study their regulation by hormones like aldosterone and vasopressin. MDCK-C11 cells from passages 78 to 86 were utilized. The reaction to determine H+-ATPase activity was started by addition of cell homogenates to tubes contained the assay medium. The inorganic phosphate (Pi) released was determined by a colorimetric method modified from that described by Fiske and Subbarow. Changes in intracellular calcium concentration in the cells was determined using the Ca2+-sensing dye fluo-4 AM. Homogenates of MDCK-C11 cells present a bafilomycin-sensitive activity (vacuolar H+-ATPase), and a vanadate-sensitive activity (H+/K+-ATPase). The bafilomycin-sensitive activity showed a pH optimum of 6.12. ATPase activity was also stimulated in a dose-dependent fashion as K+ concentration was increased between 0 and 50 mmol·L–1, with an apparent Km for the release of Pi of 0.13 mmol·L–1 and Vmax of 22.01 nmol·mg–1·min–1. Incubation of cell monolayers with 10−8 mol·L–1 aldosterone for 24 h significantly increased vacuolar H+-ATPase activity, an effect prevented by 10−5 mol·L–1 spironolactone. Vacuolar H+-ATPase activity was also stimulated by 10−11 mol·L–1 vasopressin, an effect prevented by a V1 receptor-specific antagonist. This dose of vasopressin determined a sustained rise of cytosolic ionized calcium. We conclude that (i) homogenates of MDCK-C11 cells present a bafilomycin-sensitive (H+-ATPase) activity and a vanadate-sensitive (H+/K+-ATPase) activity, and (ii) vacuolar H+-ATPase activity is activated by aldosterone through a genomic pathway and by vasopressin through V1 receptors.
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Affiliation(s)
- Priscilla M.C. Dos Santos
- Department of Physiology, Division of Biological Sciences, Federal University of Paraná (UFPR), Paraná, Brazil
| | - Fabio P. Freitas
- Department of Physiology, Division of Biological Sciences, Federal University of Paraná (UFPR), Paraná, Brazil
| | - Jeane Mendes
- Department of Physiology, Division of Biological Sciences, Federal University of Paraná (UFPR), Paraná, Brazil
| | - Ana Lucia Tararthuch
- Department of Physiology, Division of Biological Sciences, Federal University of Paraná (UFPR), Paraná, Brazil
| | - Ricardo Fernandez
- Department of Physiology, Division of Biological Sciences, Federal University of Paraná (UFPR), Paraná, Brazil
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Kinoshita H, Okabayashi M, Kaneko M, Yasuda M, Abe K, Machida A, Ohkubo T, Kamata T, Yakushiji F. Shakuyaku-kanzo-to induces pseudoaldosteronism characterized by hypokalemia, rhabdomyolysis, metabolic alkalosis with respiratory compensation, and increased urinary cortisol levels. J Altern Complement Med 2009; 15:439-43. [PMID: 19388868 DOI: 10.1089/acm.2008.0397] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Licorice, the primary ingredient of the Japanese herbal medicine shakuyaku-kanzo-to, can cause pseudoaldosteronism. Thus, shakuyaku-kanzo-to can cause this condition. CASE DESCRIPTION A 79-year-old woman was brought to the emergency room. She had been experiencing general fatigue, numbness in the hands, and weakness in the lower limbs and could not stand up without assistance. She presented with hypokalemia (potassium level, 1.7 mEq/L), increased urinary excretion of potassium (fractional excretion of K, 21.2%), abnormalities on an electrocardiogram (flat T waves in II, III, AVF, and V1-6), rhabdomyolysis (creatine kinase level, 28,376 U/L), myopathy, metabolic alkalosis with respiratory compensation (O(2) flow rate, 2 L/min; pH, 7.473; pco(2), 61.0 mm Hg; po(2), 78.0 mm Hg; HCO(3), 44.1 mmol/L), hypertension (174/93 mm Hg), hyperglycemia (blood glucose level, 200-300 mg/dL), frequent urination, suppressed plasma renin activity (0.1 ng/mL/hour), decreased aldosterone levels (2.6 ng/dL), and increased urinary cortisol levels (600.6 microg/day; reference range, 26.0-187.0 microg/day). CONCLUSIONS In this case, the observed reduction in the urinary cortisol levels, from 600.6 to 37.8 microg/day, led to a definitive diagnosis of pseudoaldosteronism instead of the apparent mineralocorticoid excess syndrome. Discontinuing shakuyaku-kanzo-to treatment and administering spironolactone and potassium proved effective in improving the patient's condition. Medical practitioners prescribing shakuyaku-kanzo-to should take into account the association between licorice, which is its main ingredient, and pseudoaldosteronism.
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Affiliation(s)
- Hiroyuki Kinoshita
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan.
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Prieto de Paula J, Franco Hidalgo S. Algunas precisiones sobre la monografía “Combatiendo la EPOC”. Rev Clin Esp 2009; 209:257-8. [DOI: 10.1016/s0014-2565(09)71247-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Faridi AB, Weisberg LS. Acid-Base, Electrolyte, and Metabolic Abnormalities. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Palmer BF, Naderi ASA. Metabolic complications associated with use of thiazide diuretics. ACTA ACUST UNITED AC 2007; 1:381-92. [DOI: 10.1016/j.jash.2007.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 07/21/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
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Buchanan IB, Campbell BT, Peck MD, Cairns BA. Chest Wall Necrosis and Death Secondary to Hydrochloric Acid Infusion for Metabolic Alkalosis. South Med J 2005; 98:822-4. [PMID: 16144181 DOI: 10.1097/01.smj.0000172781.27664.87] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Central line complications are common, and extravasation injuries related to infusion of caustic substances have been previously described. Although hydrochloric acid has been used for many years to treat metabolic alkalosis, there have been no reported fatal complications. We report the case of a 53-year-old female who received a fatal chemical burn due to extravasation from a subclavian central venous catheter of hydrochloric acid infused to correct severe metabolic alkalosis. This case illustrates the hazards of the infusion of caustic substances through central lines and underscores the importance of constant vigilance regarding line positioning and changes to the surrounding tissues when infusing these substances.
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Affiliation(s)
- Ian B Buchanan
- North Carolina Jaycee urn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7228, USA
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Abstract
Vacuolar H(+)-ATPases are ubiquitous multisubunit complexes mediating the ATP-dependent transport of protons. In addition to their role in acidifying the lumen of various intracellular organelles, vacuolar H(+)-ATPases fulfill special tasks in the kidney. Vacuolar H(+)-ATPases are expressed in the plasma membrane in the kidney almost along the entire length of the nephron with apical and/or basolateral localization patterns. In the proximal tubule, a high number of vacuolar H(+)-ATPases are also found in endosomes, which are acidified by the pump. In addition, vacuolar H(+)-ATPases contribute to proximal tubular bicarbonate reabsorption. The importance in final urinary acidification along the collecting system is highlighted by monogenic defects in two subunits (ATP6V0A4, ATP6V1B1) of the vacuolar H(+)-ATPase in patients with distal renal tubular acidosis. The activity of vacuolar H(+)-ATPases is tightly regulated by a variety of factors such as the acid-base or electrolyte status. This regulation is at least in part mediated by various hormones and protein-protein interactions between regulatory proteins and multiple subunits of the pump.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology, Univ. of Zurich, Winterthurerstrasse 190, CH-8057 Zurich, Switzerland.
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Hernández Vázquez J, de Miguel Díez J, Llorente Iñigo D. Hypercapnia Does Not Always Require Mechanical Ventilation. ARCHIVOS DE BRONCONEUMOLOGÍA ((ENGLISH EDITION)) 2004; 40:334-5. [PMID: 15225523 DOI: 10.1016/s1579-2129(06)60314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dubé L, Daenen S, Kouatchet A, Soltner C, Alquier P. [Severe metabolic alkalosis following hypokalemia from a paraneoplastic Cushing syndrome]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:860-4. [PMID: 11803847 DOI: 10.1016/s0750-7658(01)00518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Metabolic alkalosis is frequently observed in critically ill patients. Etiologies are numerous but endocrinal causes are rare. We report a case of a patient with severe respiratory insufficiency, metabolic alkalosis and hypokalemia. The evolution was fatal. Further explorations revealed an ectopic Adrenocorticotropine Hormone syndrome. The initial tumor was probably a small cell lung carcinoma.
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Affiliation(s)
- L Dubé
- Département d'anesthésie-réanimation, CHU Angers, 4, rue Larrey, 49035 Angers, France.
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Schepkens H, Lameire N. Gitelman's syndrome: an overlooked cause of chronic hypokalemia and hypomagnesemia in adults. Acta Clin Belg 2001; 56:248-54. [PMID: 11603254 DOI: 10.1179/acb.2001.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 1966, Gitelman described a benign variant of classical Bartter's syndrome in adults characterized by consistent hypomagnesemia and hypocalciuria, hypokalemic metabolic alkalosis and hyperreninemic hyperaldosteronism with normal blood pressure. A specific gene has been found responsible for this disorder, encoding the thiazide-sensitve Na-Cl coporter (TSC) in the distal convoluted tubule. Mutant alleles result in loss of normal TSC function and the phenotype is identical to patients with chronic use of thiazide diuretics. Gitelman's syndrome is a more common cause of chronic hypokalemia than Bartter's syndrome, with which it is often confused. The distinguishing features between both syndromes are discussed.
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Affiliation(s)
- H Schepkens
- Dienst voor Inwendige Ziekten-Afdeling Nefrologie Universitair Ziekenhuis De Pintelaan 185-9000 Gent.
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43
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Pochet JM, Laterre PF, Jadoul M, Devuyst O. Metabolic alkalosis in the intensive care unit. Acta Clin Belg 2001; 56:2-9. [PMID: 11307479 DOI: 10.1179/acb.2001.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- J M Pochet
- Service de Néphrologie, Clinique Sainte-Elisabeth, Namur
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