1 / 109

Buffers

Buffers. HA [H + ] . [ A - ]. Kidneys. H 2 po 4 1- [H + ] [ H po 4 2- ]. Case Study. A 4-year-old girl was admitted to the emergency room because of poor intake, vomiting, fever and abdominal pain over the last 3 days. Mother denied any history of drug ingestion.

alesia
Download Presentation

Buffers

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Buffers

  2. HA [H+].[A-]

  3. Kidneys

  4. H2 po41-[H+] [ H po42- ]

  5. Case Study • A 4-year-old girl was admitted to the emergency room because of poor intake, vomiting, fever and abdominal pain over the last 3 days. • Mother denied any history of drug ingestion. • Past medical history is significant for recurrent urinary tract infections. • The BP was 90/57 mmHg, PR 90/min, and respirations 32/min

  6. Case Study (cont’d) • Laboratory data on admission revealed a serum Na+ of 135 mEq/, K + 6.2 mEq/L, Cl- 117 mEq/L, HCO3- 10 mEq/L, BUN 23 mg/dL, creatinine 0.4mg/dL,glucose 100 mg/dL, calcium 9.2 mg/dL, phosphorous 4.0 mg/dL, uric acid 4.8 mg/dL. • Arterial blood pH was 7.10, and pCO2 28 mmHg.

  7. Case Study (cont’d) • Urinalysis showed a pH of 6.5, negative for blood or protein. • The urine sediment was normal. • Urine Cl- was 52, Na+ 68, and K+ 25.

  8. Quiz • What acid-base is present? • What is the most likely diagnosis? • What investigation would establish the diagnosis?

  9. Step 1 What is the primary acid-base disturbance? • Metabolic acidosis is the primary acid-base disorder: - Low blood pH (7.10) • - Low HCO3- level (10 mEq/L)

  10. Step 2 Is the metabolic acidosis associated with a normal or an increased anion gap?AG = Na+ - (Cl- + HCO3-)

  11. Patient has a normal AG acidosis • Serum AG = (135) - [(117+16)] • = (135) - (133) • = 12 mEq/L • The fall in serum HCO3- level in this patient is matched by an equal rise in the serum Cl- concentration, thus the patient has normal anion gap acidosis

  12. Causes of normal AG acidosis • GI bicarbonate loss • Use of carbonic anhydrase • Hyperalimentation • Ureteral diversions • NH4Cl infusions • Renal tubular acidosis (RTA)

  13. Step 3 Is the respiratory compensation adequate? • pCO2 = 1.2 HCO3- • pCO2 = 1.2 (25-10) or 18 mmHg • Expected pCO2 = (40-18) = 22 mmHg • Patient’s pCO2 = 28 mmHg • Patient’s pCO2 > the expected pCO2 Respiratory Acidosis

  14. Our patient has a mixed acid-base disorder • Normal AG metabolic acidosis plusRespiratory acidosis

  15. The urine AG • Urine AG = (UC +) - (UA-) • Urine Cl- > Urine (Na+ + K+)

  16. The usefulness of the urine AG in the evaluation of distal RTA • A negative urine AG suggests the presence of a normal distal urinary acidification • A positive urine AG (Na+ + K +) > Cl- suggests the presence of impaired distal urinary acidification

  17. Urine AG as an index of NH4- excretion • NH4+ is an unmeasured cation and its excretion at the distal tubule is usually accompanied by Cl- excretion (NH4Cl) • The urinary AG should become progressively negative as the rate of NH4Cl excretion increases • Under normal condition the urine AG is negative

  18. Classification of RTA • Classic distal RTA (RTA-1) • Proximal RTA (RTA-2) • Hyperkalemic distal RTA (RTA-IV)

  19. Quiz What is the most likely diagnosis? • The most likely diagnosis is RTA-IV • 1. Normal AG acidosis • 2. Hyperkalemia • 3. Urine pH >5.5 • 4. Positive urine AG

  20. Quiz What is the most likely cause of RTA-IV? • A. Acute non-obstructive pyelonephritis • B. Acute pyelonephritis with VUR • C. Addison disease • D. Non-obstructive pyelonephritis B. Pyelonephritis with VUR

  21. Quiz What investigations you order to confirm this diagnosis? • A. Renal sonogram • B. Urine β2 microglobulin • C. DMSA scan • D. VCUG • E. DTPA scan A. Renal sonogram

  22. Our patient has a positive urine AG Urine (Na+ + UK+) > Urine Cl- • Urine AG = [(Na+ + K+ )] - (Cl-) • = [(68 + 25)] -(52) • = (93) - (52) • = 41 mEq/L • The positive urine AG is consistent with the impaired distal urinary acidification

  23. Differential diagnosis of impaired distal renal acidification • Classic distal RTA (RTA-I) • Hyperkalemic distal RTA (RTA-IV)

  24. RTA-1 Urine pH >5.5 Severe hypokalemia Low urine citrate exc Nephrocalcinosis Urolithiasis RTA-IV Urine pH varies hyperkalemia Normal urine citrate Decreased renin and aldosterone secretion Characteristics of RTA

  25. Causes of classic distal RTA (RTA-I) • Idiopathic • Familial • Hypercalciuria • Amphotricin B • Chronic active hepatitis • Medullary sponge kidney

  26. Causes of hyperkalemicdistal RTA (RTA-IV) • Urinary tract obstruction • Vesicoureteral reflux • Interstitial nephritis • Systemic lupus erythematosis • Diabetes mellitus • Primary hypoaldosteronism

  27. Case Study • A 12-year-old girl was admitted to the emergency department in a semi-comatose condition. Blood pressure was 110/65 mmHg; pulse 87/min; and respiratory rate 22/min. The remainder of the PE was normal. • Laboratory data on admission revealed serum Na+ of 135 mEq/, K + 2.1 mEq/L, Cl- 117 mEq/L, HCO3- 10 mEq/L, BUN 13 mg/dL, creatinine 0.4 mg/dL, and glucose 90 mg/dL.

  28. Case study (cont’d) • Arterial blood pH was 7.10, and PCO2 33 mmHg. Urinalysis showed a pH of 7.0. The urine sediment was normal • The patient was intubated and potassium was given intravenously.

  29. Quiz • What acid-base disorder is present? • What is the most likely diagnosis? • What investigation would establish the diagnosis?

  30. Step 1: Review ABG data What is the primary acid-base disturbance? • Blood pH =7.10 • HCO3- = 10 mEq/L • PCO2 = 33 mmHg The findings of low HCO3- and low pH suggest a primary metabolic acidosis

  31. Step 3: Review serum electrolytes? Is the metabolic acidosis associated with a normal or an increased anion gap? • Serum AG = (135) - [(117+16)] • patient has normal AG acidosis • = (135) - (133) Normal AG =12 mEq/L

  32. Step 2: Assess respiratory compensation Is the respiratory compensation adequate? • Patient’s PCO2 = 33 mmHg ∆PCO2 = 1.2 ∆HCO3- • ∆PCO2 = 1.2 (25-10) or 18 mmHg • Expected PCO2 = (40-18) = 22 mmHg Patient’s PCO2> the expected pCO2

More Related