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Disorders
Presented byDr. Hasan Hafizur Rahman
Phase- A resident student
Dept.of Nephrology.DMC.
Definitions
Acid (HA) is defined as a compound that can release a
proton (H+)
Acidosis (acidaemia) is defined as a disorder with
accumulation of acids in the extended ECV. The pH in the
arterial blood is < 7.35
Base (B-)is defined as a compound can bind H+
Conti Buffer
Combination of a weak acid and /or a weak base
and its salt
What does it do?
Resists changes in pH
Effectiveness depends on
pK of buffering system
pH of environment in which it is placed
pK:
Negative log of the ionization constant of an acid
Strong acids would have a pK <3
Strong base would have a pK >9
pH
Negative log of the hydrogen ion concentration
pH= pK + log([base]/[acid])
Represents the hydrogen concentration
pH Review
pH = - log [H+]
H+ is really a proton
Range is from 0 - 14
If [H+] is high, the solution is acidic; pH < 7
If [H+] is low, the solution is basic or alkaline; pH > 7
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Production of acids
CO2 is a potential acid as H2CO3, and because the lungs
eliminate it, it is called a volatile acid. Production of CO2
is up to 24 mol daily.
Non-volatile acids:
a) Organic acids are continually produced as a byproduct of metabolism:
- lactic acid.ketoacids, Fatty acids
Under normal conditions, these acids are completely
metabolized to CO2 and H2O. They have no effect on
proton balance.
HCO3-/CO2-buffer system
HCO3- and CO2 are present in ratio of about 20 : 1.
CO2 is dissolved in the plasma and it is constantly
exchanging with CO2 in the gas phase of the alveoli
of the lungs.
Henderson-Hasselbalch Equation
Relationship between pH and the bicarbonatecarbonic acid buffer system in plasma
Allows us to calculate pH
Henderson-Hasselbalch Equation
General Equation
pH = pK + log AHA
Bicarbonate/Carbonic Acid system
o
Alkalosis
Ketoacidosis (diabetic)
Uremia (renal failure)
Salicylate intoxication
Starvation
Methanol intoxication
Alcohol ketoacidosis
Unmeasured osmoles (intoxication)
Lactic acidosis
Acid-Base Imbalances
The body response to acid-base imbalance is called
compensation
May be complete if brought back within normal
limits
Partial compensation if range is still outside
norms.
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Compensation
If underlying problem is metabolic, hyperventilation
or hypoventilation can help : respiratory
compensation.
If problem is respiratory, renal mechanisms can
bring about metabolic compensation.
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Diagnosis of Acid-Base
Imbalances
1. To be noted whether the pH is low (acidosis) or high
(alkalosis)
2. To decide which value, pCO2 or HCO3- , is outside the
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THANKS A LOT.
Compensatory Response
One half of acid load is buffered by nonbicarbonate buffers= Bone,
protein, red cells..
PCO2 (Kussmaul)
compensatory response after 15-30 minutes,
5 days up to maximal
Kidney:
Metabolic acidosis
processing of glutamine into NH4+ (ammonia to ammonium for
better H-excretion)
and
Bicarbonate generation (and reclaiming)
Respiratory Acidosis
Acute increase in pCO2
Kidneys compensation:
Increase net acid excretion,
(48 hours for fully development)
Underlying cause:
Central nervous system disease,
lung (COPD)and heart disease,
sedatives and opiates depressing the respiratory
center
Hypercapnic encephalopathy can develop
Metabolic Alkalosis
Plasma bicarbonate [HCO3-] = pH
1) H+ GI loss or shift into cells
2) Excess HCO3Administration of bicarbonate, or precursors:
lactate, acetate, citrate or
Failure to excrete: mineralocorticoid effect
3) Loss of fluid wih
Diuretic therapy
[Cl-, [K+] and [H+] loss from plasmaextracellular volume contraction
Respiratory Alkalosis
pCO2 , pH due to:
Hypoxia (compensatory hyperventilation)
Acute: pulmonary edema or emboli, pneumonia,
Chronic: severe anemia, high altitude, hypotension
Respiratory center stimulation
Pregnancy, Anxiety, Fever, heat stroke, sepsis, salisylate
intox., cerebral disease, hepatic cirrhosis,
Increased mechanical ventilation
Respiratory Alkalosis
Most common acid-base disorder
Physiologic in pregnancy and high altitude
Bad prognosis in critically ill patients
(the higher hypocapnia, the higher mortality)
Hyperventilation,
Perioral and extremity paresthesias,
Light-headedness,
Muscle cramps,
Hyperreflexia, seizures, ionized Ca tetany
Acid-Base Balance
Function
Maintains pH homeostasis
Maintenance of H+ concentration
Potential Problems of Acid-Base balance
Increased H+ concentration yields decreased pH
Decreased H+ concentration yields increased pH
Regulation of pH
H+ + HCO3-
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Control of Acids
1. Buffer systems
Take up H+ or release H+ as conditions
change
Buffer pairs weak acid and a base
Exchange a strong acid or base for a
weak one
Results in a much smaller pH change
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Bicarbonate buffer
Sodium Bicarbonate (NaHCO3) and
carbonic acid (H2CO3)
Maintain a 20:1 ratio : HCO3- : H2CO3
HCl + NaHCO3 H2CO3 + NaCl
NaOH + H2CO3 NaHCO3 + H2O
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Phosphate buffer
Major intracellular buffer
H+ + HPO42- H2PO4 OH- + H2PO4- H2O + H2PO42-
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Protein Buffers
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2. Respiratory mechanisms
Exhalation of carbon dioxide
Powerful, but only works with volatile
acids
Doesnt affect fixed acids like lactic acid
CO2 + H20 H2CO3 H+ + HCO3 Body pH can be adjusted by changing rate
and depth of breathing
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3. Kidney excretion
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Rates of correction
Buffers function almost instantaneously
Respiratory mechanisms take several
minutes to hours
Renal mechanisms may take several
hours to days
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Acidosis
Principal effect of acidosis is depression of the
CNS through in synaptic transmission.
Generalized weakness
Deranged CNS function the greatest threat
Severe acidosis causes
Disorientation
coma
death
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Alkalosis
Alkalosis causes over excitability of the central
and peripheral nervous systems.
Numbness
Lightheadedness
It can cause :
Nervousness
muscle spasms or tetany
Convulsions
Loss of consciousness
Death
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Respiratory Acidosis
Carbonic acid excess caused by blood
levels of CO2 above 45 mm Hg.
Hypercapnia high levels of CO2 in blood
Chronic conditions:
Depression of respiratory center in brain that
controls breathing rate drugs or head
trauma
Paralysis of respiratory or chest muscles
Emphysema
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Respiratory Acidosis
Acute conditons:
Adult Respiratory Distress Syndrome
Pulmonary edema
Pneumothorax
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Breathlessness
Restlessness
Lethargy and disorientation
Tremors, convulsions, coma
Respiratory rate rapid, then gradually
depressed
Skin warm and flushed due to vasodilation
caused by excess CO2
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Respiratory Alkalosis
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Respiratory Alkalosis
Conditions that stimulate respiratory
center:
Oxygen deficiency at high altitudes
Pulmonary disease and Congestive heart
failure caused by hypoxia
Acute anxiety
Fever, anemia
Early salicylate intoxication
Cirrhosis
Gram-negative sepsis
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Compensation of Respiratory
Alkalosis
Kidneys conserve hydrogen ion
Excrete bicarbonate ion
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Metabolic Acidosis
Bicarbonate deficit - blood concentrations of
bicarb drop below 22mEq/L
Causes:
Loss of bicarbonate through diarrhea or renal
dysfunction
Accumulation of acids (lactic acid or ketones)
Failure of kidneys to excrete H+
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Headache, lethargy
Nausea, vomiting, diarrhea
Coma
Death
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Metabolic Alkalosis
Bicarbonate excess - concentration in
blood is greater than 26 mEq/L
Causes:
Excess vomiting = loss of stomach acid
Excessive use of alkaline drugs
Certain diuretics
Endocrine disorders
Heavy ingestion of antacids
Severe dehydration
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Example
A patient is in intensive care because he
suffered a severe myocardial infarction 3
days ago. The lab reports the following
values from an arterial blood sample:
pH 7.3
HCO3- = 20 mEq / L ( 22 - 26)
pCO2 = 32 mm Hg (35 - 45)
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Diagnosis
Metabolic acidosis
With compensation
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