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Nagami GT, Kraut JA. The Role of the Endocrine System in the Regulation of Acid-Base Balance by the Kidney and the Progression of Chronic Kidney Disease. Int J Mol Sci 2024; 25:2420. [PMID: 38397097 PMCID: PMC10889389 DOI: 10.3390/ijms25042420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
Systemic acid-base status is primarily determined by the interplay of net acid production (NEAP) arising from metabolism of ingested food stuffs, buffering of NEAP in tissues, generation of bicarbonate by the kidney, and capture of any bicarbonate filtered by the kidney. In chronic kidney disease (CKD), acid retention may occur when dietary acid production is not balanced by bicarbonate generation by the diseased kidney. Hormones including aldosterone, angiotensin II, endothelin, PTH, glucocorticoids, insulin, thyroid hormone, and growth hormone can affect acid-base balance in different ways. The levels of some hormones such as aldosterone, angiotensin II and endothelin are increased with acid accumulation and contribute to an adaptive increase in renal acid excretion and bicarbonate generation. However, the persistent elevated levels of these hormones can damage the kidney and accelerate progression of CKD. Measures to slow the progression of CKD have included administration of medications which inhibit the production or action of deleterious hormones. However, since metabolic acidosis accompanying CKD stimulates the secretion of several of these hormones, treatment of CKD should also include administration of base to correct the metabolic acidosis.
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Affiliation(s)
- Glenn T. Nagami
- Nephrology Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA;
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Jeffrey A. Kraut
- Nephrology Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA;
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
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Nagami GT, Kraut JA. Regulation of Acid-Base Balance in Patients With Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:337-342. [PMID: 36175071 DOI: 10.1053/j.ackd.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
Normallly the kidneys handle the daily acid load arising from net endogenous acid production from the metabolism of ingested animal protein (acid) and vegetables (base). With chronic kidney disease, reduced acid excretion by the kidneys is primarily due to reduced ammonium excretion such that when acid excertion falls below acid porduction, acid accumulation occurs. With even mild reductions in glomerular filtration rate (60 to 90 ml/min), net acid excretion may fall below net acid production resulting in acid retention which may be initially sequestered in interstitial compartments in the kidneys, bones, and muscles resulting in no fall in measured systemic bicarbonate levels (eubicarbonatemic metabolic acidosis). With greater reductions in kidney function, the greater quantities of acid retained spillover systemically resulting in low pH (overt metabolic acidosis). The evaluation of acid-base balance in patients with CKD is complicated by the heterogeneity of clinical acid-base disorders and by the eubicarbonatemic nature of the early phase of acid retention. If supported by more extensive studies, blood gas analyses to confirm the acid-base disorder and newer ways for assessing the presence of acidosis such as urinary citrate measurements may become routine tools to evaluate and treat acid-base disorders in individuals with CKD.
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Affiliation(s)
- Glenn T Nagami
- Division of Nephrology, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA.
| | - Jeffrey A Kraut
- Division of Nephrology, VHAGLA Healthcare System, Los Angeles, CA; UCLA Membrane Biology Laboratory, David Geffen UCLA School of Medicine, Los Angeles, CA
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Berkmann JC, Herrera Martin AX, Ellinghaus A, Schlundt C, Schell H, Lippens E, Duda GN, Tsitsilonis S, Schmidt-Bleek K. Early pH Changes in Musculoskeletal Tissues upon Injury-Aerobic Catabolic Pathway Activity Linked to Inter-Individual Differences in Local pH. Int J Mol Sci 2020; 21:ijms21072513. [PMID: 32260421 PMCID: PMC7177603 DOI: 10.3390/ijms21072513] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 01/09/2023] Open
Abstract
Local pH is stated to acidify after bone fracture. However, the time course and degree of acidification remain unknown. Whether the acidification pattern within a fracture hematoma is applicable to adjacent muscle hematoma or is exclusive to this regenerative tissue has not been studied to date. Thus, in this study, we aimed to unravel the extent and pattern of acidification in vivo during the early phase post musculoskeletal injury. Local pH changes after fracture and muscle trauma were measured simultaneously in two pre-clinical animal models (sheep/rats) immediately after and up to 48 h post injury. The rat fracture hematoma was further analyzed histologically and metabolomically. In vivo pH measurements in bone and muscle hematoma revealed a local acidification in both animal models, yielding mean pH values in rats of 6.69 and 6.89, with pronounced intra- and inter-individual differences. The metabolomic analysis of the hematomas indicated a link between reduction in tricarboxylic acid cycle activity and pH, thus, metabolic activity within the injured tissues could be causative for the different pH values. The significant acidification within the early musculoskeletal hematoma could enable the employment of the pH for novel, sought-after treatments that allow for spatially and temporally controlled drug release.
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Affiliation(s)
- Julia C. Berkmann
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Berlin-Brandenburg School for Regenerative Therapies, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Aaron X. Herrera Martin
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Berlin-Brandenburg School for Regenerative Therapies, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Agnes Ellinghaus
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
| | - Claudia Schlundt
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Hanna Schell
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Evi Lippens
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Georg N. Duda
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
| | - Serafeim Tsitsilonis
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, 13357 Berlin, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
- Correspondence: ; Tel.: +49-(0)30-450-659209; Fax: +49-(0)30-450-559938
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Nagami GT, Hamm LL. Regulation of Acid-Base Balance in Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:274-279. [PMID: 29031353 DOI: 10.1053/j.ackd.2017.07.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/28/2017] [Indexed: 11/11/2022]
Abstract
The kidneys play a major role in the regulation of acid-base balance by reabsorbing bicarbonate filtered by the glomeruli and excreting titratable acids and ammonia into the urine. In CKD, with declining kidney function, acid retention and metabolic acidosis occur, but the extent of acid retention depends not only on the degree of kidney impairment but also on the dietary acid load. Acid retention can occur even when the serum bicarbonate level is apparently normal. With reduced kidney function, acid transport processes in the surviving nephrons are augmented but as disease progresses ammonia excretion and, in some individuals, the ability to reabsorb bicarbonate falls, whereas titratable acid excretion is preserved until kidney function is severely impaired. Urinary ammonia levels are used to gauge the renal response to acid loads and are best assessed by direct measurement of urinary ammonia levels rather than by indirect assessments. In individuals with acidosis from CKD, an inappropriately low degree of ammonia excretion points to the pathogenic role of impaired urinary acid excretion. The presence of a normal bicarbonate level in CKD complicates the interpretation of the urinary ammonia excretion as such individuals could be in acid-base balance or could be retaining acid without manifesting a low bicarbonate level. At this time, the decision to give bicarbonate supplementation in CKD is reserved for those with a bicarbonate level of 22 mEq/L, but because of potential harm of overtreatment, supplementation should be adjusted to maintain a bicarbonate level of <26 mEq/L.
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Frick KK, Asplin JR, Culbertson CD, Granja I, Krieger NS, Bushinsky DA. Persistence of 1,25D-induced hypercalciuria in alendronate-treated genetic hypercalciuric stone-forming rats fed a low-calcium diet. Am J Physiol Renal Physiol 2014; 306:F1081-7. [PMID: 24573387 DOI: 10.1152/ajprenal.00680.2013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Genetic hypercalciuric stone-forming (GHS) rats demonstrate increased intestinal Ca absorption, increased bone resorption, and reduced renal tubular Ca reabsorption leading to hypercalciuria and all form kidney stones. GHS have increased vitamin D receptors (VDR) at these sites of Ca transport. Injection of 1,25(OH)2D3 (1,25D) leads to a greater increase in urine (u)Ca in GHS than in control Sprague-Dawley (SD), possibly due to the additional VDR. In GHS the increased uCa persists on a low-Ca diet (LCD) suggesting enhanced bone resorption. We tested the hypothesis that LCD, coupled to inhibition of bone resorption by alendronate (alen), would eliminate the enhanced 1,25D-induced hypercalciuria in GHS. SD and GHS were fed LCD and half were injected daily with 1,25D. After 8 days all were also given alen until euthanasia at day 16. At 8 days, 1,25D increased uCa in SD and to a greater extent in GHS. At 16 days, alen eliminated the 1,25D-induced increase in uCa in SD. However, in GHS alen decreased, but did not eliminate, the 1,25D-induced hypercalciuria, suggesting maximal alen cannot completely prevent the 1,25D-induced bone resorption in GHS, perhaps due to increased VDR. There was no consistent effect on mRNA expression of renal transcellular or paracellular Ca transporters. Urine CaP and CaOx supersaturation (SS) increased with 1,25D alone in both SD and GHS. Alen eliminated the increase in CaP SS in SD but not in GHS. If these results are confirmed in humans with IH, the use of bisphosphonates, such as alen, may not prevent the decreased bone density observed in these patients.
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Affiliation(s)
- Kevin K Frick
- Research Assistant Professor of Medicine, Univ. of Rochester School of Medicine and Dentistry, Division of Nephrology, Dept. of Medicine, 601 Elmwood Ave., Box 675, Rochester, NY 14642.
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The role of metabolic acidosis in chronic kidney diseases. ASIAN BIOMED 2010. [DOI: 10.2478/abm-2010-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background and objectives: This review focuses on three areas, basic acid-base physiology especially concerning hydrogen ion balance, development of acidosis in chronic kidney disease (CKD), and the consequences of acidosis. We highlight what is well established, what is less certain, and what is unknown. Method and results: The literature on acidosis in CKD were searched from 2004 to 2010 utilizing PubMed, Google Scholar, and Ovid to augment the classic work on acid base physiology over the past three decades. The original research in endogenous acid production and net acid excretion were reviewed. Touching upon the development of metabolic acidosis in CKD, we focused on the consequences of chronic metabolic acidosis on growth and other important variables. Finally, we recognize the significant issue of patients’ medical non-compliance and presented treatment strategy to counter this problem. Conclusion: The correction of acidosis in chronic kidney disease needs no advocacy. The case is made conclusively. Patient non-compliance because of the medication that needs to be taken several times a day is a problem, requiring due diligence.
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Abstract
Bone growth and turnover results from the coordinated activities of two key cell types. Bone matrix is deposited and mineralised by osteoblasts and it is resorbed by osteoclasts, multinucleate cells that excavate pits on bone surfaces. It has been known since the early 20th century that systemic acidosis causes depletion of the skeleton, an effect assumed to result from physico-chemical dissolution of bone mineral. However, our own work has shown that resorption pit formation by cultured osteoclasts was absolutely dependent on extracellular acidification; these cells are inactive at pH levels above about 7·3 and show maximum stimulation at a pH of about 6·9. Bone resorption is most sensitive to changes in H+concentration at a pH of about 7·1 (which may be close to the interstitial pH in bone). In this region pH shifts of <0·05 units can cause a doubling or halving of pit formation. In whole-bone cultures, chronic HCO3-acidosis results in similar stimulations of osteoclast-mediated Ca2+release, with a negligible physico-chemical component.In vivo, severe systemic acidosis (pH change of about –0·05 to –0·20) often results from renal disease; milder chronic acidosis (pH change of about –0·02 to –0·05) can be caused by excessive protein intake, acid feeding, prolonged exercise, ageing, airway diseases or the menopause. Acidosis can also occur locally as a result of inflammation, infection, wounds, tumours or diabetic ischaemia. Cell function, including that of osteoblasts, is normally impaired by acid; the unusual stimulatory effect of acid on osteoclasts may represent a primitive ‘fail-safe’ that evolved with terrestrial vertebrates to correct systemic acidosis by ensuring release of alkaline bone mineral when the lungs and kidneys are unable to remove sufficient H+equivalent. The present results suggest that even subtle chronic acidosis could be sufficient to cause appreciable bone loss over time.
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Affiliation(s)
- Tim Arnett
- Department of Anatomy and Developmental Biology, University College London, Gower Street, London WC1E 6BT, UK.
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Affiliation(s)
- T R Arnett
- Department of Anatomy and Developmental Biology, University College London, UK
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Affiliation(s)
- D G Warnock
- San Francisco Veterans Administration Medical Center, California
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Morrison G, Murray TG. Electrolyte, acid-base, and fluid homeostasis in chronic renal failure. Med Clin North Am 1981; 65:429-47. [PMID: 7230965 DOI: 10.1016/s0025-7125(16)31533-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Rahilly GT, Berl T. Severe metabolic alkalosis caused by administration of plasma protein fraction in end-stage renal failure. N Engl J Med 1979; 301:824-6. [PMID: 481514 DOI: 10.1056/nejm197910113011506] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
A review of the experience with 66 patients on chronic hemodialysis who underwent 67 major surgical procedures is presented. There were 58 general surgical procedures, and nine major cardiovascular procedures including four emergency cardiac valve replacements. The preoperative, intraoperative and postoperative management of these patients is discussed as well as the morbidity and mortality encountered. It is concluded that patients on well-managed chronic dialysis will tolerate minor and major surgery well and renal failure should no longer be regarded as a relative contraindication for appropriate elective or emergency surgery.
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Berg U, Aperia A, Broberger O. Subclinical defects in renal regulation of acid base balance in children with recurrent urinary tract infections. ACTA PAEDIATRICA SCANDINAVICA 1971; 60:521-7. [PMID: 5110534 DOI: 10.1111/j.1651-2227.1971.tb06984.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Rodriguez-Soriano J. The renal regulation of acid-base balance and the disturbances noted in renal tubular acidosis. Pediatr Clin North Am 1971; 18:529-45. [PMID: 4939563 DOI: 10.1016/s0031-3955(16)32564-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Baerg RD, Kimberg DV, Gershon E. Effect of renal insufficiency on the active transport of calcium by the small intestine. J Clin Invest 1970; 49:1288-300. [PMID: 5422027 PMCID: PMC322593 DOI: 10.1172/jci106341] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The intestinal absorption of calcium is often depressed in patients with chronic renal insufficiency. Furthermore, the malabsorption of calcium and the osteodystrophy which occur in association with chronic renal disease are often "resistant" to vitamin D; the basis for this resistance remains uncertain however. Recent studies by others have emphasized the role of an abnormality in the metabolism of vitamin D in accounting for the alterations in the calcium absorption and the apparent vitamin D-resistance which accompany the uremic syndrome. The present studies with an experimentally uremic animal model demonstrate a defect in the active transport of calcium by duodenal gut sacs in vitro. This abnormality is not due to the semistarvation associated with renal insufficiency and cannot be corrected by the administration of physiologic amounts of vitamin D(3): it is reversed by massive doses of the vitamin. Neither the metabolism of vitamin D(3) nor the levels of calcium binding protein activity in the duodenal mucosa are affected by renal insufficiency under the conditions employed in the present studies. The results of the present studies strongly suggest that in addition to the recently proposed mechanism involving an interference with the metabolism of vitamin D renal insufficiency also affects the cellular mechanisms for calcium transport in a manner which, while opposite in direction to that of vitamin D, is independent of a direct interaction with the vitamin or its metabolites.
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Kiil F, Enger E. Compensatory changes in renal electrolyte excretion to removal of gastric HC1 in normal and uremic man. Scand J Clin Lab Invest 1968; 22:277-87. [PMID: 5741793 DOI: 10.3109/00365516809167064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 39-1968. N Engl J Med 1968; 279:705-13. [PMID: 5695301 DOI: 10.1056/nejm196809262791311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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