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Gantsova E, Serova O, Vishnyakova P, Deyev I, Elchaninov A, Fatkhudinov T. Mechanisms and physiological relevance of acid-base exchange in functional units of the kidney. PeerJ 2024; 12:e17316. [PMID: 38699185 PMCID: PMC11064853 DOI: 10.7717/peerj.17316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Abstract
This review discusses the importance of homeostasis with a particular emphasis on the acid-base (AB) balance, a crucial aspect of pH regulation in living systems. Two primary organ systems correct deviations from the standard pH balance: the respiratory system via gas exchange and the kidneys via proton/bicarbonate secretion and reabsorption. Focusing on kidney functions, we describe the complexity of renal architecture and its challenges for experimental research. We address specific roles of different nephron segments (the proximal convoluted tubule, the loop of Henle and the distal convoluted tubule) in pH homeostasis, while explaining the physiological significance of ion exchange processes maintained by the kidneys, particularly the role of bicarbonate ions (HCO3-) as an essential buffer system of the body. The review will be of interest to researchers in the fields of physiology, biochemistry and molecular biology, which builds a strong foundation and critically evaluates existing studies. Our review helps identify the gaps of knowledge by thoroughly understanding the existing literature related to kidney acid-base homeostasis.
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Affiliation(s)
- Elena Gantsova
- Avtsyn Research Institute of Human Morphology of Federal State Budgetary Scientific Institution “Petrovsky National Research Centre of Surgery”, Moscow, Russia
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Oxana Serova
- Shemyakin–Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russian Federation
| | - Polina Vishnyakova
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, Moscow, Russian Federation
| | - Igor Deyev
- Shemyakin–Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russian Federation
| | - Andrey Elchaninov
- Avtsyn Research Institute of Human Morphology of Federal State Budgetary Scientific Institution “Petrovsky National Research Centre of Surgery”, Moscow, Russia
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Timur Fatkhudinov
- Avtsyn Research Institute of Human Morphology of Federal State Budgetary Scientific Institution “Petrovsky National Research Centre of Surgery”, Moscow, Russia
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
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Bemand TJ, Chatoor R, Natale P, Strippoli G, Delaney A. Acetazolamide for metabolic alkalosis complicating respiratory failure with chronic obstructive pulmonary disease or obesity hypoventilation syndrome: a systematic review. Thorax 2023; 78:1004-1010. [PMID: 37217290 DOI: 10.1136/thorax-2023-219988] [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: 01/03/2023] [Accepted: 03/03/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Metabolic alkalosis may lead to respiratory inhibition and increased need for ventilatory support or prolongation of weaning from ventilation for patients with chronic respiratory disease. Acetazolamide can reduce alkalaemia and may reduce respiratory depression. METHODS We searched Medline, EMBASE and CENTRAL from inception to March 2022 for randomised controlled trials comparing acetazolamide to placebo in patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome or obstructive sleep apnoea, hospitalised with acute respiratory deterioration complicated by metabolic alkalosis. The primary outcome was mortality and we pooled data using random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 (Risk of Bias 2) tool, heterogeneity was assessed using the I2 value and χ2 test for heterogeneity. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. RESULTS Four studies with 504 patients were included. 99% of included patients had chronic obstructive pulmonary disease. No trials recruited patients with obstructive sleep apnoea. 50% of trials recruited patients requiring mechanical ventilation. Risk of bias was overall low to some risk. There was no statistically significant difference with acetazolamide in mortality (relative risk 0.98 (95% CI 0.28 to 3.46); p=0.95; 490 participants; three studies; GRADE low certainty) or duration of ventilatory support (mean difference -0.8 days (95% CI -7.2 to 5.6); p=0.36; 427 participants; two studies; GRADE: low certainty). CONCLUSION Acetazolamide may have little impact on respiratory failure with metabolic alkalosis in patients with chronic respiratory diseases. However, clinically significant benefits or harms are unable to be excluded, and larger trials are required. PROSPERO REGISTRATION NUMBER CRD42021278757.
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Affiliation(s)
- Timothy John Bemand
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
- Rural Clinical School Wagga Wagga Campus, University of New South Wales, Wagga Wagga, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard Chatoor
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
- Rural Clinical School Wagga Wagga Campus, University of New South Wales, Wagga Wagga, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giovanni Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Division of Critical Care, The George Institute for Global Health, Newtown, New South Wales, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, ANZIC-RC, Melbourne, Victoria, Australia
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Yi Y. Post-Hypercapnic Alkalosis: A Brief Review. Electrolyte Blood Press 2023; 21:18-23. [PMID: 37434801 PMCID: PMC10329906 DOI: 10.5049/ebp.2023.21.1.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 07/13/2023] Open
Abstract
Metabolic alkalosis is a common acid-base imbalance frequently observed in intensive care unit (ICU) patients and is associated with increased mortality. Post-hypercarbia alkalosis (PHA) is a type of metabolic alkalosis caused by sustained high serum bicarbonate levels following a rapid resolution of hypoventilation in patients with chronic hypercapnia due to prolonged respiratory disturbance. Common causes of chronic hypercapnia include chronic obstructive pulmonary disease (COPD), central nervous system disorders, neuromuscular disorders, and narcotic abuse. Rapid correction of hypercapnia through hyperventilation leads to a swift normalization of pCO2, which lacks renal compensation, consequently causing an increase in plasma HCO3- levels and severe metabolic alkalosis. Most of PHA occurs in the ICU setting requiring mechanical ventilation and can progress severe alkalemia due to secondary mineralocorticoid excess from volume depletion or decreased HCO3- excretion from decreased glomerular filtration rate and increased proximal tubular reabsorption. PHA is associated with increased ICU stay, ventilator dependency, and mortality. Acetazolamide, a carbonic anhydrase inhibitor, has been utilized for managing PHA by inducing alkaline diuresis and reducing tubular reabsorption of bicarbonate. While acetazolamide effectively improves alkalemia, its impact on hard outcomes may be limited by factors such as patient complexity, co-administered medications, and underlying conditions contributing to alkalosis.
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Affiliation(s)
- Yongjin Yi
- Division of Nephrology, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
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Greiner RC, Beasley HM, Bodhireddy H, Bouterse CR, Eggleston MT, Pfeiffer DC. Revisiting acidosis in acetazolamide treatment of severe glaucoma: A case report. Am J Ophthalmol Case Rep 2022; 27:101658. [PMID: 35845746 PMCID: PMC9278045 DOI: 10.1016/j.ajoc.2022.101658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/22/2022] [Accepted: 07/05/2022] [Indexed: 11/08/2022] Open
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Côté JM, Goulamhoussen N, McMahon BA, Murray PT. Diuretic combinations in critically ill patients with respiratory failure: A systematic review and meta-analysis. World J Crit Care Med 2022; 11:178-191. [PMID: 36331969 PMCID: PMC9136719 DOI: 10.5492/wjccm.v11.i3.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/11/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In patients with respiratory failure, loop diuretics remain the cornerstone of the treatment to maintain fluid balance, but resistance is common.
AIM To determine the efficacy and safety of common diuretic combinations in critically ill patients with respiratory failure.
METHODS We searched MEDLINE, Embase, Cochrane Library and PROSPERO for studies reporting the effects of a combination of a loop diuretic with another class of diuretic. A meta-analysis using mean differences (MD) with 95% confidence interval (CI) was performed for the 24-h fluid balance (primary outcome) and the 24-h urine output, while descriptive statistics were used for safety events.
RESULTS Nine studies totalling 440 patients from a total of 6510 citations were included. When compared to loop diuretics alone, the addition of a second diuretic is associated with an improved negative fluid balance at 24 h [MD: -1.06 L (95%CI: -1.46; -0.65)], driven by the combination of a thiazide plus furosemide [MD: -1.25 L (95%CI: -1.68; -0.82)], while no difference was observed with the combination of a loop-diuretic plus acetazolamide [MD: -0.40 L (95%CI: -0.96; 0.16)] or spironolactone [MD: -0.65 L (95%CI: -1.66; 0.36)]. Heterogeneity was high and the report of clinical and safety endpoints varied across studies.
CONCLUSION Based on limited evidence, the addition of a second diuretic to a loop diuretic may promote diuresis and negative fluid balance in patients with respiratory failure, but only when using a thiazide. Further larger trials to evaluate the safety and efficacy of such interventions in patients with respiratory failure are required.
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Affiliation(s)
- Jean Maxime Côté
- Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal H2X0C1, Québec, Canada
| | - Nadir Goulamhoussen
- Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal H2X0C1, Québec, Canada
| | - Blaithin A McMahon
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Patrick T Murray
- Department of Medicine, School of Medicine, University College Dublin, Dublin D078NN, Ireland
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Hao JQ, He XY, Yang X, Xiao YC, Duan SQ, Wang H, Bai H, Zhang Y, Shi JY, Zhu XL, Wang ZZ, Hao CY, Duan HB. Acetazolamide Alleviate Cerebral Edema Induced by Ischemic Stroke Through Inhibiting the Expression of AQP4 mRNA. Neurocrit Care 2021; 36:97-105. [PMID: 34302276 DOI: 10.1007/s12028-021-01261-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We want to investigate the effect of aquaporin-4 (AQP4) on cerebral edema induced by ischemic stroke in rats and explore whether inhibiting the expression of AQP4 through acetazolamide (AZA) could attenuate brain edema and protect cerebral function. METHODS The Sprague Dawley (SD) rats were randomly divided into four groups: sham + saline group, sham + AZA group, AZA intervention group, and nonintervention group. Each group was divided into five subgroups according to the time of cerebral ischemia (6 h, 1 day, 3 days, 5 days, and 7 days). The model of cerebral infarction in rats was adopted by means of the bilateral carotid arteries ligation (2-VO) method. The rats in intervention group were given intraperitoneal injection of AZA (35 mg/kg/day). Hematoxylin-eosin staining was performed for pathological analysis of the infarcted area. The brain water content was calculated to evaluate the degree of brain edema. The messenger RNA (mRNA) and protein expressions of AQP4 in the brain were measured by quantitative real-time polymerase chain reaction and immunohistochemistry, respectively. RESULTS Significant cerebral pathological damages were found in ischemic stroke rats. The brain water content, protein, and mRNA expression of AQP4 of the intervention and nonintervention groups were markedly higher than those of the sham groups. By contrast, AZA administration reduced the brain water content, whereas improved cerebral dysfunction was induced by ischemic stroke. Moreover, AZA obviously reduced the protein and mRNA expression of AQP4 after ischemic stroke in rats' brains. CONCLUSIONS The expression of AQP4 was closely related to cerebral edema induced by ischemic stroke. Decreasing the expression of AQP4 mRNA by AZA administration can effectively relieve cerebral edema and decrease cerebral pathological damage.
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Affiliation(s)
- Jia-Qi Hao
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Xing-Yue He
- The School of Nursing of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Xin Yang
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - You-Chao Xiao
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Sheng-Qiang Duan
- Department of Neurosurgery, The First Affiliated Hospital of Hebei North University, 12 Changqing Road, Zhangjiakou, Hebei, People's Republic of China
| | - Huan Wang
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China
| | - Hao Bai
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Yu Zhang
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Jia-Ying Shi
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Xiao-Lin Zhu
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Zhuang-Zhuang Wang
- The First Clinical Medical College of Shanxi Medical University, 86 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Chun-Yan Hao
- Department of Geriatrics, The First Hospital of Shanxi Medical University, 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China.
| | - Hu-Bin Duan
- Department of Neurosurgery, The First Hospital of Shanxi Medical University, 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China. .,Department of Neurosurgery, Lvliang People's Hospital, 277 Binhebei Middle Road, Lvliang, Shanxi, People's Republic of China.
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Schmickl CN, Owens RL, Orr JE, Edwards BA, Malhotra A. Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence. BMJ Open Respir Res 2021; 7:7/1/e000557. [PMID: 32332024 PMCID: PMC7204833 DOI: 10.1136/bmjresp-2020-000557] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/29/2020] [Indexed: 02/04/2023] Open
Abstract
Introduction Acetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk of commonly reported side effects based on meta-analyses. We hypothesised that these risks are dose-dependent. Methods We queried MEDLINE/EMBASE (Medical Literature Analysis and Retrieval System Online/Excerpta Medica dataBASE) up until 04/10/2019, including any randomised placebo-controlled trial in which adults received oral AZM versus placebo reporting side effects. Eligibility assessment was performed by two independent reviewers. Data were abstracted by one reviewer who verified key entries at a second time point. For side effects reported by >3 studies a pooled effect estimate was calculated, and heterogeneity assessed via I2; for outcomes reported by >5 studies effect modification by total daily dose (EMbyTDD; <400 mg/d, 400–600 mg/d, >600 mg/d) was assessed via meta-regression. For pre-specified, primary outcomes (paraesthesias, taste disturbances, polyuria and fatigue) additional subgroup analyses were performed using demographics, intervention details, laboratory changes and risk of bias. Results We included 42 studies in the meta-analyses (Nsubjects=1274/1211 in AZM/placebo groups). AZM increased the risk of all primary outcomes (p<0.01, I2 ≤16% and low-to-moderate quality of evidence for all)—the numbers needed to harm (95% CI; nStudies) for each were: paraesthesias 2.3 (95% CI 2 to 2.7; n=39), dysgeusia 18 (95% CI 10 to 38, n=22), polyuria 17 (95% CI 9 to 49; n=22), fatigue 11 (95% CI 6 to 24; n=14). The risk for paraesthesias (beta=1.8 (95% CI 1.1 to 2.9); PEMbyTDD=0.01) and dysgeusia (beta=3.1 (95% CI 1.2 to 8.2); PEMbyTDD=0.02) increased with higher AZM doses; the risk of fatigue also increased with higher dose but non-significantly (beta=2.6 (95% CI 0.7 to 9.4); PEMbyTDD=0.14). Discussion This comprehensive meta-analysis of low-to-moderate quality evidence defines risk of common AZM side effects and corroborates dose dependence of some side effects. These results may inform clinical decision making and support efforts to establish the lowest effective dose of AZM for various conditions.
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Affiliation(s)
- Christopher N Schmickl
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Robert L Owens
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeremy E Orr
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Clayton, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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Tobias JD. Metabolic Alkalosis in the Pediatric Patient: Treatment Options in the Pediatric ICU or Pediatric Cardiothoracic ICU Setting. World J Pediatr Congenit Heart Surg 2021; 11:776-782. [PMID: 33164684 DOI: 10.1177/2150135120942488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Metabolic alkalosis is characterized by the primary elevation of the serum bicarbonate concentration with a normal or elevated partial pressure of carbon dioxide. Although there may be several potential etiologies in the critically ill patient in the pediatric or cardiothoracic intensive care unit, metabolic alkalosis most commonly results from diuretic therapy with chloride loss. In most cases, the etiology can be determined by a review of the patient's history and medication record. Although generally innocuous with limited impact on physiologic function, metabolic alkalosis may impair central control of ventilation, especially when weaning from mechanical ventilation. The following manuscript presents the normal homeostatic mechanisms that control pH, reviews the etiology of metabolic alkalosis, and outlines the differential diagnosis. Options and alternatives for treatment including pharmacologic interventions are presented with a focus on these conditions as they pertain to the patient in the pediatric or cardiac intensive care unit.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus and The Ohio State University College of Medicine, Columbus, OH, USA
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Solaimanzadeh I. Nifedipine and Amlodipine Are Associated With Improved Mortality and Decreased Risk for Intubation and Mechanical Ventilation in Elderly Patients Hospitalized for COVID-19. Cureus 2020; 12:e8069. [PMID: 32411566 PMCID: PMC7219014 DOI: 10.7759/cureus.8069] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Dihydropyridine calcium channel blockers (CCB) are typically used agents in the clinical management of hypertension. Yet, they have also been utilized in the treatment of various pulmonary disorders with vasoconstriction. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been implicated in the development of vasoconstrictive, proinflammatory, and pro-oxidative effects. A retrospective review was conducted on CCB use in hospitalized patients in search of any difference in outcomes related to specific endpoints: survival to discharge and progression of disease leading to intubation and mechanical ventilation. The electronic medical records for all patients that tested positive for SARS-CoV-2 that were at or above the age of 65 and that expired or survived to discharge from a community hospital in Brooklyn, NY, between the start of the public health crisis due to the viral disease up until April 13, 2020, were included. Of the 77 patients that were identified, 18 survived until discharge and 59 expired. Seven patients from the expired group were excluded since they died within one day of presentation to the hospital. Five patients were excluded from the expired group since their age was above that of the eldest patient in the survival group (89 years old). With 65 patients left, 24 were found to have been administered either amlodipine or nifedipine (CCB group) and 41 were not (No-CCB group). Patients treated with a CCB were significantly more likely to survive than those not treated with a CCB: 12 (50%) survived and 12 expired in the CCB group vs. six (14.6%) that survived and 35 (85.4%) that expired in the No-CCB treatment group (P<.01; p=0.0036). CCB patients were also significantly less likely to undergo intubation and mechanical ventilation. Only one patient (4.2%) was intubated in the CCB group whereas 16 (39.0%) were intubated in the No-CCB treatment group (P<.01; p=0.0026). Nifedipine and amlodipine were found to be associated with significantly improved mortality and a decreased risk for intubation and mechanical ventilation in elderly patients hospitalized with COVID-19. Further clinical studies are warranted. Including either nifedipine or amlodipine in medication regimens for elderly patients with hypertension hospitalized for COVID-19 may be considered.
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Cole JL. Acetazolamide Causes Worsening Acidosis in Uncompensated COPD Exacerbations: Increased Awareness Needed for Patient Safety. J Emerg Med 2020; 58:953-958. [PMID: 32241707 DOI: 10.1016/j.jemermed.2020.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 11/25/2019] [Accepted: 01/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Acetazolamide has been studied extensively in post-hypercapnic alkalosis as a tool to facilitate ventilator weaning in chronic obstructive pulmonary disease (COPD). It has also been utilized to facilitate respiratory drive in nonmechanically ventilated patients with COPD. Although this is generally a forgiving intervention, providers must carefully select patients for this medication, as it can cause severe acidosis and deterioration of clinical status in severe COPD cases. The present report describes two cases of patients who developed worsening acidosis and hypercapnia after receiving acetazolamide in acute respiratory failure. CASE REPORT Case 1 was a 72-year-old obese male with COPD who was dependent on supplemental oxygen and presented to the emergency department (ED) with acute on chronic hypercapnic respiratory failure. He was given a one-time dose of acetazolamide in the ED for "respiratory failure made worse by severe metabolic alkalosis." His arterial blood gas (ABG) worsened overnight, accompanied by decreased mental status: pH 7.32, paCO2 82 mm Hg, paO2 50 mm Hg, HCO3 41.7 mmol/L, FiO2 32% to pH 7.21, paCO2 91.7 mm Hg, paO2 59 mm Hg, HCO3 36.6 mmol/L, and FiO2 32%. Case 2 was a 62-year-old male with COPD who was dependent on supplemental oxygen and presented to the ED with acute on chronic hypercapnic respiratory failure. He was given acetazolamide in the ED with similar results: ABG on presentation pH 7.37, paCO2 79.3 mm Hg, paO2 77.6 mm Hg, HCO3 45.5 mmol/L, and FiO2 32%. The next morning, ABG was pH 7.29, paCO2 79 mm Hg, paO2 77 mm Hg, HCO3 45.5 mmol/L, and FiO2 32%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acetazolamide given early in the uncompensated setting can worsen acidosis and potentiate clinical deterioration.
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Affiliation(s)
- Jennifer L Cole
- Veterans Healthcare System of the Ozarks, Fayetteville, Arkansas
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Tanios BY, Omran MO, Noujeim C, Lotfi T, Mallat SS, Bou-Khalil PK, Akl EA, Itani HS. Carbonic anhydrase inhibitors in patients with respiratory failure and metabolic alkalosis: a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:275. [PMID: 30371345 PMCID: PMC6205780 DOI: 10.1186/s13054-018-2207-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/24/2018] [Indexed: 11/22/2022]
Abstract
Background Metabolic alkalosis is common in patients with respiratory failure and may delay weaning in mechanically ventilated patients. Carbonic anhydrase inhibitors block renal bicarbonate reabsorption, and thus reverse metabolic alkalosis. The objective of this systematic review is to assess the benefits and harms of carbonic anhydrase inhibitor therapy in patients with respiratory failure and metabolic alkalosis. Methods We searched the following electronic sources from inception to August 2017: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and SCOPUS. Randomized clinical trials were included if they assessed at least one of the following outcomes: mortality, duration of hospital stay, duration of mechanical ventilation, adverse events, and blood gas parameters. Teams of two review authors worked in an independent and duplicate manner to select eligible trials, extract data, and assess risk of bias of the included trials. We used meta-analysis to synthesize statistical data and then assessed the certainty of evidence using the GRADE methodology. Results Six eligible studies were identified with a total of 564 participants. The synthesized data did not exclude a reduction or an increase in mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.57 to 1.56) or in duration of hospital stay (mean difference (MD) 0.42 days, 95% CI −4.82 to 5.66) with the use of carbonic anhydrase inhibitors. Carbonic anhydrase inhibitor therapy resulted in a decrease in the duration of mechanical ventilation of 27 h (95% CI −50 to −4). Also, it resulted in an increase in PaO2 (MD 11.37 mmHg, 95% CI 4.18 to 18.56) and a decrease in PaCO2 (MD −4.98 mmHg, 95% CI −9.66, −0.3), serum bicarbonate (MD −5.03 meq/L, 95% CI −6.52 to −3.54), and pH (MD −0.04, 95% CI −0.07 to −0.01). There was an increased risk of adverse events in the carbonic anhydrase inhibitor group (RR 1.71, 95% CI 0.98 to 2.99). Certainty of evidence was judged to be low for most outcomes. Conclusion In patients with respiratory failure and metabolic alkalosis, carbonic anhydrase inhibitor therapy may have favorable effects on blood gas parameters. In mechanically ventilated patients, carbonic anhydrase inhibitor therapy may decrease the duration of mechanical ventilation. A major limitation of this finding was that only two trials assessed this clinically important outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2207-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bassem Y Tanios
- Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maryam O Omran
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Carlos Noujeim
- Division of pulmonary and critical care, Keserwan Medical Center, Ghazir, Lebanon
| | - Tamara Lotfi
- Clinical Research Institute, and Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Samir S Mallat
- Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon. .,Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Pierre K Bou-Khalil
- Division of Pulmonary and Critical Care, American University of Beirut Medical Center, Beirut, Lebanon. .,Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Houssam S Itani
- Division of Nephrology and Hypertension, Makassed General Hospital, Beirut, Lebanon
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Van Berkel MA, Elefritz JL. Evaluating off-label uses of acetazolamide. Am J Health Syst Pharm 2018; 75:524-531. [DOI: 10.2146/ajhp170279] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Jessica L. Elefritz
- Department of Pharmacy, Wexner Medical Center, Ohio State University, Columbus, OH
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Sierra CM, Hernandez EA, Parbuoni KA. Use of Arginine Hydrochloride in the Treatment of Metabolic Alkalosis or Hypochloremia in Pediatric Patients. J Pediatr Pharmacol Ther 2018; 23:111-118. [PMID: 29720912 DOI: 10.5863/1551-6776-23.2.111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Dosing of arginine for treatment of hypochloremia or metabolic alkalosis is laborious and has inherent variability in dose selection. The primary objective of this study was to determine the efficacy of arginine in the treatment of metabolic alkalosis and hypochloremia. Secondary objectives were to determine an optimal dose, route, and frequency for arginine administration in the treatment of these conditions. METHODS This single center, retrospective, descriptive study was conducted in children who received arginine for treatment of hypochloremia or metabolic alkalosis. Treatment success was assessed by measuring serum chloride and bicarbonate concentrations after arginine administration. RESULTS Of the 464 orders analyzed, 177 met inclusion criteria in 82 unique patients. Fifty percent (n = 81) of arginine administrations used to manage hypochloremia saw normalization of abnormal chloride levels, and 83% (n = 62) of arginine administrations used to treat metabolic alkalosis saw normalization of abnormal bicarbonate levels. Patients who received arginine to resolve hypochloremia were statistically significantly more likely to have their hypochloremia resolve if they used alternative dosing methods compared to established dosing methods (76 vs. 5, p = 0.001). However, this relationship was not seen for patients with metabolic alkalosis (11 vs. 51, p = 1.000). The median percentage of calculated daily dose of arginine needed for resolution of hypochloremia was 59% and was 35% for metabolic alkalosis. CONCLUSIONS Arginine is effective to improve metabolic alkalosis and hypochloremia. Established dosing methods are not more effective than other methods in resolving metabolic alkalosis or hypochloremia. Further prospective studies are warranted to validate these results.
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Rialp Cervera G, Raurich Puigdevall J, Morán Chorro I, Martín Delgado M, Heras la Calle G, Mas Serra A, Vallverdú Perapoch I. Effects of early administration of acetazolamide on the duration of mechanical ventilation in patients with chronic obstructive pulmonary disease or obesity-hypoventilation syndrome with metabolic alkalosis. A randomized trial. Pulm Pharmacol Ther 2017; 44:30-37. [DOI: 10.1016/j.pupt.2017.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/11/2017] [Accepted: 03/05/2017] [Indexed: 10/20/2022]
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Abstract
OBJECTIVE Patients in PICUs frequently present hypochloremic metabolic alkalosis secondary to loop diuretic treatment, especially those undergoing cardiac surgery. This study evaluates the effectiveness of acetazolamide therapy for metabolic alkalosis in PICU patients. DESIGN Retrospective, observational study. SETTING A tertiary care children's hospital PICU. PATIENTS Children receiving at least a 2-day course of enteral acetazolamide. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic variables, diuretic treatment and doses of acetazolamide, urine output, serum electrolytes, urea and creatinine, acid-base excess, pH, and use of mechanical ventilation during treatment were collected. Patients were studied according to their pathology (postoperative cardiac surgery, decompensated heart failure, or respiratory disease). A total of 78 episodes in 58 patients were identified: 48 were carried out in cardiac postoperative patients, 22 in decompensated heart failure, and eight in respiratory patients. All patients received loop diuretics. A decrease in pH and PCO2 in the first 72 hours, a decrease in serum HCO3 (mean, 4.65 ± 4.83; p < 0.001), and an increase in anion gap values were observed. Urine output increased in cardiac postoperative patients (4.5 ± 2.2 vs 5.1 ± 2.0; p = 0.020), whereas diuretic treatment was reduced in cardiac patients. There was no significant difference in serum electrolytes, blood urea, creatinine, nor chloride after the administration of acetazolamide from baseline. Acetazolamide treatment was well tolerated in all patients. CONCLUSIONS Acetazolamide decreases serum HCO3 and PCO2 in PICU cardiac patients with metabolic alkalosis secondary to diuretic therapy. Cardiac postoperative patients present a significant increase in urine output after acetazolamide treatment.
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Does Acetazolamide Really Promote Ventilator Weaning in Critically Ill Children With Metabolic Alkalosis? Pediatr Crit Care Med 2016; 17:1191-1193. [PMID: 27918394 DOI: 10.1097/pcc.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gulsvik R, Wyller TB. Surgjørende diuretika ved respirasjonssvikt? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014. [DOI: 10.4045/tidsskr.13.1469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Cao J, Zhang J, Li C, Feng J. Correspondence. Br J Hosp Med (Lond) 2013. [DOI: 10.12968/hmed.2013.74.11.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jie Cao
- Respiratory Department Tianjin Medical University General Hospital Tianjin 300052 China
| | - Jing Zhang
- Respiratory Department Tianjin Medical University General Hospital Tianjin 300052 China
| | - Caili Li
- Respiratory Department Tianjin Medical University General Hospital Tianjin 300052 China
| | - Jing Feng
- Respiratory Department Tianjin Medical University General Hospital Tianjin 300052 China
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