Binding of calcium to serum albumin. II. Effect of pH via competitive hydrogen and calcium ion binding to the imidazole groups of albumin

Measurement of plasma total calcium before plasma free ionized calcium - a possibility with affordable pitfalls

Free ionized calcium (fCa) is considered the gold standard for assessing calcium status in patients, but it is relatively expensive and is associated with several preanalytical and analytical error sources. We investigated the feasibility of using a reflex test that involves first measuring total calcium (tCa) and if out of reference range, then measure fCa, with expectation of reducing the number of fCa measurements. We used data from 1815 unique patients with concurrent measurement of fCa, tCa and albumin adjusted calcium (aCa). Patients were stratified by albumin level, and the association of fCa to tCa and aCa respectively was assessed with linear regression. The regression analysis showed the best linearity for tCa and aCa at albumin <35 g/L (R2: 0.80-0.90), and the poorest at albumin >40 g/L (R2: tCa 0.58; aCa 0.59). We examined the accuracy of hypo- and hypercalcemia classifications for tCa, aCa and the reflex test. aCa had more misclassifications of hypo- and hypercalcemia than tCa, with respectively 25% and 21%. Implementation of the reflex test would correct any false hypo- or hypercalcemia classified by tCa, leaving only false negative results corresponding to 9% of all tCa measurements. False negative results were on average 0.04 mmol/L above or below the reference range of fCa. Implementation of the reflex test reduces the number of fCa by 68% without major errors diagnosing hyper- or hypocalcemia.

Reconsidering the role of albumin towards amorphous calcium phosphate-based calciprotein particles formation and stability from a physico-chemical perspective

The formation of calciprotein particles (CPPs) in serum is a physiological phenomenon fundamental to prevent the rise of ectopic calcifications. CPPs are colloidal hybrid particles made of amorphous calcium phosphate stabilized by a protein, fetuin-A. Since albumin is the most abundant protein present in serum, we aimed at understanding if it plays a synergic action together with fetuin-A towards CPPs formation and stability. CPPs were prepared using a constant fetuin-A concentration (5 µM) and different concentrations of albumin (0-606 µM). The stability of CPPs, their crystallization and sedimentation were followed in situ by combining turbidimetry, precipitation analysis and dynamic light scattering. The morphology was investigated by scanning electron microscopy and cryo-transmission electron microscopy, while crystallinity was inspected by infrared spectroscopy. The effect of albumin on the amount of formed CPPs was also studied, as well as the amount of protein adsorbed on CPPs. We found that albumin is not able to prolong the lifetime of the amorphous phase, but it is very effective in delaying the sedimentation of CPPs after crystallization. Albumin also significantly decreases the amount and size of CPPs when present in their synthetic medium, likely playing a fundamental role in our organism together with fetuin-A towards the stabilization of CPPs.

Negative dietary cation-anion difference in prepartum dairy cow diets: a pragmatic study in two commercial dairy farms

Pragmatic studies, evaluating the effectiveness of an intervention under its usual conditions, are less commonly reported than the explanatory trials. For instance, the effectiveness of prepartum negative dietary cation-anion difference (DCAD) diets on inducing a compensated metabolic acidosis that promotes a higher blood Ca concentration at calving has not been frequently described under commercial farm management conditions without researchers' interference. Thus, the objectives were to study cows under commercial farm management conditions to (1) describe the daily close-up dairy cows' urine pH and fed DCAD, and (2) evaluate the association between urine pH and fed DCAD, and preceding urine pH and blood Ca at calving. A total of 129 close-up Jersey cows about to commence their ≥2nd lactation were enrolled in the study after 7 days of exposure to DCAD diets in two commercial dairy herds. Urine pH was determined daily from mid-stream urine samples from enrollment to calving. Fed DCAD was determined from feed bunk samples obtained during 29 (Herd 1) and 23 (Herd 2) consecutive days. Plasma Ca concentration was determined within 12 h after calving. Descriptive statistics were generated at the herd- and cow-level. Multiple linear regression was used to evaluate the associations between urine pH and fed DCAD for each herd, and preceding urine pH and plasma Ca concentration at calving for both herds. At herd-level, the average urine pH and CV during the study period were 6.1 and 12.0% (Herd 1) and 5.9 and 10.9% (Herd 2), respectively. At the cow-level, the average urine pH and CV during the study period were 6.1 and 10.3% (Herd 1) and 6.1 and 12.3% (Herd 2), respectively. During the study period, fed DCAD averages were -121.3 and -165.7 mEq/kg of DM and CV 22.8 and 60.6% for Herd 1 and Herd 2, respectively. No evidence of association between cows' urine pH and fed DCAD was observed in Herd 1, whereas a quadratic association was observed in Herd 2. When both herds were combined, a quadratic association was observed between the urine pH intercept (at calving) and plasma Ca concentration. Although average urine pH and fed DCAD were within recommended ranges, the high variability observed indicates that acidification and fed DCAD are not constant, and often outside the recommended ranges in commercial settings. Monitoring of DCAD programs is warranted to ensure their effectiveness under commercial settings.

Trauma-induced hypocalcemia

BACKGROUND

Trauma-induced hypocalcemia is an underappreciated complication of severe injury but is well known to result in the derangement of an array of physiological regulatory mechanisms. Existing literature provides a compelling link between hypocalcemia and worse trauma-induced coagulopathy and increased mortality after injury.

STUDY DESIGN AND METHODS

This narrative review evaluates available data related to the risk factors, mechanisms, and treatment of hypocalcemia after severe injury. The authors did not perform a systemic review or meta-analysis.

RESULTS AND DISCUSSION

The interplay of acidosis, hypothermia, and coagulopathy with hypocalcemia potentiates the bloody vicious cycle of hemorrhagic shock which has been the paradigm of trauma resuscitation for over half a century. However, current screening and treatment of postinjury hypocalcemia are relegated to a secondary consideration in trauma resuscitation. We conclude calcium supplementation should be a primary tier intervention for life-threatening injury.

The pathophysiology of leg cramping during dialysis and the use of carnitine in its treatment

Leg cramping is a common side effect of hemodialysis, and this is frequently treated by the administration of carnitine, but this is not effective in every patient. Alkalosis is a key component of the etiology of leg cramping during hemodialysis sessions. This is mediated through the binding of calcium ions to serum albumin, which causes hypocalcemia, and an increase in the release of calcium ions from the sarcoplasmic reticulum. Normally the calcium pump on the sarcoplasmic reticulum consumes ATP and quickly reuptakes the released calcium ions, which rapidly stops excessive muscle contractions. Thus, carnitine deficiency results in prolonged muscle contraction because of ATP depletion. However, during ATP production, carnitine is only involved up to the stage of acyl-CoA transport into mitochondria, and for the efficient generation of ATP, the subsequent metabolism of acyl-CoA is also important. For example, β-oxidation and the tricarboxylic acid cycle may be affected by a deficiency of water-soluble vitamins and the electron transport chain requires coenzyme Q10, but statins inhibit its production. The resulting accumulation of excess long-chain acyl-CoA in mitochondria inhibits enzymes involved in energy production. Thus, carnitine administration may be used more effectively if clinicians are aware of its specific physiologic roles.

Risk factors for high-dose methotrexate-induced nephrotoxicity

High-dose methotrexate (MTX) is widely used for the treatment of hematological malignancies. Despite the application of routine supportive care measures, such as intensive fluid hydration and urine alkalinization, nephrotoxicity is still a problem. The present study aimed to evaluate the risk factors for MTX-induced nephrotoxicity. We retrospectively reviewed 88 patients who received a regimen consisting of high-dose MTX (1000 mg/m²) and cytosine arabinoside between 2006 and 2018. Nephrotoxicity (≥ grade 2) was observed in 11 patients. Nephrotoxicity was observed only in patients with a high MTX concentration. Other than the MTX concentration, the serum uric acid level and urine pH at day 1 were associated with nephrotoxicity. A multivariate analysis revealed that urine pH was an independent risk factor for MTX-induced nephrotoxicity. Urine pH < 7.0 at day 1 was a significant risk factor for nephrotoxicity (odds ratio, 8.05; 95% confidence interval 1.95-33.3) and was also a predictor of delayed MTX elimination at 72 h after injection. Among pre-treatment factors, a low serum calcium level predicted urine pH < 7.0 at day 1. In conclusion, the present study suggests that low urine pH at day 1 is an independent risk factor for MTX-induced nephrotoxicity.

Effects of postpartum oral calcium supplementation on milk yield, milk composition, and reproduction in multiparous Jersey and Jersey × Holstein crossbreed cows

The objective of the present study was to evaluate the effects of postpartum oral calcium supplementation on milk yield, energy-corrected milk yield, milk fat concentration, milk protein concentration, and somatic cell count linear score across the first 3 monthly tests postpartum, peak milk yield, risk of pregnancy at first service, and hazard of pregnancy by 150 d in milk on 1,129 multiparous Jersey and Jersey × Holstein crossbreed cows from 2 commercial dairies. After calving, cows were systematically assigned to control (no oral calcium supplementation; n = 567) or oral calcium supplementation at 0 and 1 d in milk (oral Ca; 50 to 60 g of calcium as boluses; n = 562). Monthly test milk yield, composition, and somatic cell count information was obtained from the Dairy Herd Improvement Association. Herd records were used for reproductive data. Statistical analysis was conducted using generalized multiple linear, Poisson, and Cox's hazard regressions. Treatment effects were evaluated considering cow-level information available at parturition (parity, breed, previous lactation milk yield, previous lactation length, dry period length, gestation length, body condition, and locomotion score at calving, calving ease, and calf sex). In addition, for a subset of cows serum calcium concentration before treatment administration was evaluated (n = 756). Overall, oral calcium supplementation did not affect the evaluated productive and reproductive variables. However, effects conditional to previous lactation length and calving locomotion score were observed. Milk yield and energy-corrected milk yield across the first 3 monthly tests were 1.8 kg/d higher for supplemented cows with a previous lactation length within the fourth quartile, compared with control cows on the same quartile. Energy-corrected milk yield tended to be 1.1 kg/d lower for supplemented cows with a previous lactation length within the first quartile, compared with control counterparts. Peak milk yield tended to be 1.6 kg higher for supplemented cows with a calving locomotion score ≥2, compared with control cows with the same locomotion score. Treatment effects were not conditional to serum calcium concentration before treatment administration. Our results suggest that postpartum oral calcium supplementation effects are conditional to cow-level factors such as previous lactation length and calving locomotion score in multiparous Jersey and Jersey × Holstein crossbreed cows.

Towards the functional high-resolution coordination chemistry of blood plasma human serum albumin

Human serum albumin (HSA) is a monomeric, globular, multi-carrier and the most abundant protein in the blood. HSA displays multiple ligand binding sites with extraordinary binding capacity for a wide range of ions and molecules. For decades, HSA's ability to bind to various ligands has led many scientists to study its physiological properties and protein structure; indeed, a better understanding of HSA-ligand interactions in human blood, at the atomic level, will likely foster the development of more potent, and overall more performant, diagnostic and therapeutic tools against serious human disorders such as diabetes, cardiovascular disorders, and cancer. Here, we present a concise overview of the current knowledge of HSA's structural characteristics, and its coordination chemistry with transition metal ions, within the scope and limitations of current techniques and biophysical methods to reach atomic resolution in solution and in blood serum. We also highlight the overwhelming need of a detailed atomistic understanding of HSA dynamic structures and interactions that are transient, weak, multi-site and multi-step, and allosterically affected by each other. Considering the fact that HSA is a current clinical tool for drug delivery systems and a potential contender as molecular cargo and nano-vehicle used in biophysical, clinical and industrial fields, we underline the emerging need for novel approaches to target the dynamic functional coordination chemistry of the human blood serum albumin in solution, at the atomic level.

Thermodynamics of the Interactions of Aminobisphosphonates and Their Calcium Complexes with Bovine Serum Albumin

Binding of bisphosphonates (BPs) to plasma proteins was investigated in the 1990s as a pharmacokinetic issue in order to fully understand bio-distribution of BP drugs which are successfully used for the treatment of several bone-related diseases. It has been hypothesized that binding to these proteins occurs with low to moderate affinity despite of unfavorable hydrophilicity of BPs, and Ca²⁺ was identified as a strong catalyst of this binding. However, these studies mainly consisted in the separation and quantification of bound and unbound drug or protein fractions using chromatographic techniques without an outcome on the molecular level. Presented thermodynamic studies analyze the interactions of three N-BPs as well as their Ca²⁺ complexes with bovine serum albumine (BSA) by means of isothermal calorimetry. The studies reveal spontaneous enthalpy favored interactions of N-BPs (amino-containing BPs) with BSA, which are enhanced by the presence of Ca²⁺ ions up to ~15-fold, strongly depending on N-BP. Those are low affinity binding events, comparable to Ca²⁺ -N-BP interactions, which most likely occur at Ca²⁺ binding site(s). It is a first example of estimation of thermodynamic forces of interactions of free and calcium-bound N-BPs with albumin.

An in silico method to predict net calcium transfer during hemodialysis

International guidelines for chronic hemodialysis patients suggest a dialysate calcium concentration between 1.25 and 1.5 mmol/L. However, it is not certain if these dialysate calcium levels result in net calcium transfer into the patient. With ubiquitous prevalence of vascular calcification in hemodialysis patients, it is pertinent to model the mass balance of calcium during dialysis. To this end, we developed a two compartmental patient model and spatiotemporal representation of dialyzer model to investigate and quantify the calcium mass balance during dialysis. The model accounts for calcium-albumin binding and varying protein concentration; the latter accounts for the Gibbs-Donnan effect. The model simulations suggest that despite a lower dialysate calcium concentration of 1.25 mmol/L, some of our patients may be loaded with calcium during dialysis. This net calcium flux from dialysate to blood side may be a potential contributor to vascular calcification, a primary cause of cardiovascular mortality in hemodialysis patients.

Acid-base alterations in ESRD and effects of hemodialysis

Acid-base alterations in patients with kidney failure and on hemodialysis (HD) treatment contribute to (1) intradialytic hypercapnia and hypoxia, (2) hemodynamic instability and cardiac arrhythmia, (3) systemic inflammation, and (4) a number of associated electrolyte alterations including potentiating effects of hypokalemia, hypocalcemia and, chronically, soft-tissue and vascular calcification, imparting poor prognosis and mortality. This paper discusses acid-base regulation and pathogenesis of dysregulation in patients with kidney failure. Major organ and systemic effects of acid-base perturbations with a specific focus on kidney failure patients on HD are emphasized, and potential mitigating strategies proposed. The high rate of HD-related complications, specifically those that can be accounted for by rapid and steep acid-base perturbations imposed by HD treatment, attests to the pressing need for investigations to establish a better dialysis regimen.

Effect of Intravenous Small-Volume Hypertonic Sodium Bicarbonate, Sodium Chloride, and Glucose Solutions in Decreasing Plasma Potassium Concentration in Hyperkalemic Neonatal Calves with Diarrhea

Background

Hyperkalemia is a frequently observed electrolyte imbalance in dehydrated neonatal diarrheic calves that can result in skeletal muscle weakness and life‐threatening cardiac conduction abnormalities and arrhythmias.

Hypothesis

Intravenous administration of a small‐volume hypertonic NaHCO₃ solution is clinically more effective in decreasing the plasma potassium concentration (cK) in hyperkalemic diarrheic calves than hypertonic NaCl or glucose solutions.

Animals

Twenty‐two neonatal diarrheic calves with cK >5.8 mmol/L.

Methods

Prospective randomized clinical trial. Calves randomly received either 8.4% NaHCO₃ (6.4 mL/kg BW; n = 7), 7.5% NaCl (5 mL/kg BW; n = 8), or 46.2% glucose (5 mL/kg BW; n = 7) IV over 5 minutes and were subsequently allowed to suckle 2 L of an electrolyte solution. Infusions with NaHCO₃ and NaCl provided an identical sodium load of 6.4 mmol/kg BW.

Results

Hypertonic NaHCO₃ infusions produced an immediate and sustained decrease in plasma cK. Hypertonic glucose infusions resulted in marked hyperglycemia and hyperinsulinemia, but cK remained unchanged for 20 minutes. Between 30 and 120 minutes after initiation of treatment, the most marked decrements in cK from baseline occurred in group NaHCO₃, which were significantly (P < .05) larger during this period of time than in calves in group NaCl, but not group glucose. After 120 minutes, the mean decrease in cK from baseline was −26 ± 10%, −9 ± 8%, and −22 ± 6% in groups NaHCO₃, NaCl, and glucose, respectively.

Conclusions/Clinical Importance

Small‐volume hypertonic NaHCO₃ infusions appear to have clinical advantages for the rapid resuscitation of hyperkalemic diarrheic calves, compared to hypertonic NaCl or glucose solutions.

Lactic Acidosis in a Patient with Type 2 Diabetes Mellitus

Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.

Size-controlled synthesis of granular polyphosphate nanoparticles at physiologic salt concentrations for blood clotting

Size-controlled granular polyphosphate (PolyP) nanoparticles were synthesized by precipitation in aqueous solutions containing physiological concentrations of calcium and magnesium. We demonstrate using dynamic light scattering (DLS) that the solubility is correlated inversely with PolyP chain length, with very long chain PolyP (PolyP1000+, more than 1000 repeating units) normally found in prokaryotes precipitating much more robustly than shorter chains like those found in human platelet dense granules (PolyP80, range 76-84 repeating units). It is believed that the precipitation of PolyP is a reversible process involving calcium coordination to phosphate monomers in the polymer chain. The particles are stable in aqueous buffer and albumin suspensions on time scales roughly equivalent to catastrophic bleeding events. Transmission electron microscopy images demonstrate that the PolyP nanoparticles are spherical and uniformly electron dense, with a particle diameter of 200-250 nm, closely resembling the content of acidocalcisomes. X-ray elemental analysis further reveals that the P/Ca ratio is 67:32. The granular nanoparticles also manifest promising procoagulant effects, as measured by in vitro clotting tests assaying contact pathway activity.

Electrolyte shifts across the artificial lung in patients on extracorporeal membrane oxygenation: interdependence between partial pressure of carbon dioxide and strong ion difference

PURPOSE

Partial pressure of carbon dioxide (PCO2), strong ion difference (SID), and total amount of weak acids independently regulate pH. When blood passes through an extracorporeal membrane lung, PCO2 decreases. Furthermore, changes in electrolytes, potentially affecting SID, were reported. We analyzed these phenomena according to Stewart's approach.

METHODS

Couples of measurements of blood entering (venous) and leaving (arterial) the extracorporeal membrane lung were analyzed in 20 patients. Changes in SID, PCO2, and pH were computed and pH variations in the absence of measured SID variations calculated.

RESULTS

Passing from venous to arterial blood, PCO2 was reduced (46.5 ± 7.7 vs 34.8 ± 7.4 mm Hg, P < .001), and hemoglobin saturation increased (78 ± 8 vs 100% ± 2%, P < .001). Chloride increased, and sodium decreased causing a reduction in SID (38.7 ± 5.0 vs 36.4 ± 5.1 mEq/L, P < .001). Analysis of quartiles of ∆PCO2 revealed progressive increases in chloride (P < .001), reductions in sodium (P < .001), and decreases in SID (P < .001), at constant hemoglobin saturation variation (P = .12). Actual pH variation was lower than pH variations in the absence of measured SID variations (0.09 ± 0.03 vs 0.12 ± 0.04, P < .001).

CONCLUSIONS

When PCO2 is reduced and oxygen added, several changes in electrolytes occur. These changes cause a PCO2-dependent SID reduction that, by acidifying plasma, limits pH correction caused by carbon dioxide removal. In this particular setting, PCO2 and SID are interdependent.

A calculation model for serum ionized calcium based on an equilibrium equation for complexation

Measurement of ionized calcium is more important than measurement of total calcium in serum samples. In the present study, equations were derived from complexation and acid dissociation equilibrium equations, and were used to determine the concentration of ionized calcium from the observed serum concentrations of total calcium, albumin, total protein, and inorganic phosphate. The ionized calcium concentration was calculated in 67 serum samples from healthy subjects and 34 outpatients previously identified as having abnormal serum calcium levels. The correlation coefficient between our method (y) and the calcium-ion-selective electrode method (x) was 0.953 and the linear regression equation was y = 0.97x at pH 7.4 with a factor of α = 0.21, which was based on the differences between the concentrations of calcium phosphorus compounds obtained by the electrode method and by calculation. The developed calculation is as useful and accurate as the electrode method, and therefore extremely useful for clinical diagnoses.

Chemical surface alteration of biodegradable magnesium exposed to corrosion media

The understanding of corrosion processes of metal implants in the human body is a key problem in modern biomaterial science. Because of the complicated and adjustable in vivo environment, in vitro experiments require the analysis of various physiological corrosion media to elucidate the underlying mechanism of "biological" metal surface modification. In this paper magnesium samples were incubated under cell culture conditions (i.e. including CO(2)) in electrolyte solutions and cell growth media, with and without proteins. Chemical mapping by high-resolution electron-induced X-ray emission spectroscopy and infrared reflection microspectroscopy revealed a complex structure of the formed corrosion layer. The presence of CO(2) in concentrations close to that in blood is significant for the chemistry of the oxidised layer. The presence of proteins leads to a less dense but thicker passivation layer which is still ion and water permeable, as osmolality and weight measurements indicate.

Treatment of lactic acidosis: appropriate confusion

BACKGROUND

Lactic acidosis (LA) is common in hospitalized patients and is associated with poor clinical outcomes. There have been major recent advances in our understanding of lactate generation and physiology. However, treatment of LA is an area of controversy and uncertainty, and the use of agents to raise pH is not clearly beneficial.

AIM AND METHODS

We reviewed animal and human studies on the pathogenesis, impact, and treatment of LA, published in the English language and available through the PubMed/MEDLINE database. Our aim was to clarify the physiology of the generation of LA, its impact on outcomes, and the different treatment modalities available. We also examined relevant data regarding LA induced by medications commonly prescribed by hospitalists: biguanides, nucleoside analog reverse-transcriptase inhibitors (NRTIs), linezolid, and lorazepam.

RESULTS/CONCLUSIONS

Lactic acid is a marker of tissue ischemia but it also may accumulate without tissue hypoperfusion. In the latter circumstance, lactic acid accumulation may be an adaptive mechanism-a novel possibility quite in contrast to the traditional view of lactic acid as only a marker of tissue ischemia. Studies on the treatment of LA with sodium bicarbonate or other buffers fail to show consistent clinical benefit. Severe acidemia in the setting of LA is a particularly poorly studied area. In the settings of medication-induced LA, optimal treatment, apart from prompt cessation of the offending agent, is still unclear.

Inductively Coupled Plasma Mass Spectrometric Analysis of Calcium Isotopes in Human Serum: A Low-Sample-Volume Acid-Equilibration Method

Background: Analytical methods for measuring the calcium isotope distribution in enriched human serum samples that use low blood volumes, simple preparation methods, and rapid analysis are important in clinical studies of calcium kinetics. Previously, sample preparation by oxalate precipitation typically required 500 μL of serum. This method was time-consuming, and the blood volume required was limiting in circumstances when only a small amount of serum could be obtained.

Methods: Serum was collected from humans who were administered 42Ca, and 20 μL of serum was mixed with 2 mL of 0.22–0.67 mol/L HNO3 at room temperature for between 1 min and 16 h. The 42Ca/43Ca ratio in the supernatant was measured by a magnetic sector inductively coupled plasma mass spectrometer (ICP-MS). Calcium isotope ratios from these equilibration solutions were compared with data from oxalate-precipitated serum samples to determine the optimum equilibrium time and the effect of acid concentration on equilibrium.

Results: Various amounts of aggregated particles developed in different acid-serum mixtures. These affected the time required for isotope equilibration in the mixture. The shortest equilibrium time needed for the calcium isotopes varied from 1 to 6 h for samples acidified with 0.22–0.45 mol/L HNO3. Data obtained from these solutions were consistent with data from oxalate-precipitated calcium. The precision of 42Ca/43Ca ratio measurements was better than 0.5%.

Conclusions: We have developed a simple, rapid sample preparation technique for ICP-MS analysis in which 20 μL of serum can be used for accurate measurement of the calcium isotope distribution in a sample with good precision and a rapid analysis time.

Use of base in the treatment of severe acidemic states

Severe acidemia (blood pH < 7.1 to 7.2) suppresses myocardial contractility, predisposes to cardiac arrhythmias, causes venoconstriction, and can decrease total peripheral vascular resistance and blood pressure, reduce hepatic blood flow, and impair oxygen delivery. These alterations in organ function can contribute to increased morbidity and mortality. Although it seemed logical to administer sodium bicarbonate to attenuate acidemia and therefore lessen the impact on cardiac function, the routine use of bicarbonate in the treatment of the most common causes of severe acidemia, diabetic ketoacidosis, lactic acidosis, and cardiac arrest, has been an issue of great controversy. Studies of animals and patients with these disorders have reported conflicting data on the benefits of bicarbonate, showing both beneficial and detrimental effects. Alternative alkalinizing agents, tris-hydroxymethyl aminomethane and Carbicarb, have shown some promise in studies of animals and humans, and reevaluation of these buffers in the treatment of severe acidemic states seems warranted. The potential value of base therapy in the treatment of severe acidemia remains an important issue, and further studies are required to determine which patients should be administered base therapy and what base should be used.

Renal tubular acidosis: a new look at an old problem

Although the definition of renal tubular acidosis (RTA) is simple, understanding the physiologic basis underlying the various types of this clinical entity is much more difficult. The pathophysiology of this disorder is reviewed using the normal acid-base functions of the involved segments of the nephron as a guide to understanding. Clinical and laboratory features of the subtypes of RTA are addressed, and diagnosis and treatment discussed. New developments in the knowledge and understanding of the associated growth disturbances, mineral metabolism, and molecular biology of RTA are also reviewed to provide the most current view of this relatively common pediatric entity.

Mechanism of adsorption of human albumin to titanium in vitro

Our previous studies have shown that human albumin is one of the main salivary proteins that adsorb to titanium (Ti). The goal of the present study was to investigate the role of electrostatic interactions in the adsorption of human albumin to Ti-oxide (TiO2) in vitro. The binding profile of human albumin to Ti was analyzed according to an adsorption isotherm. Purified human serum albumin (HSA) was suspended with native, calcium-, magnesium-, or potassium-treated commercially pure Ti powders, at pH 3.0 and 7.0. The amount of unadsorbed protein in the supernatant fluid was measured. The maximum amount of adsorbed albumin was 0.13 mg/1.0 g Ti. The albumin-Ti association constant was 2.77 mL/mg. Pretreatment of Ti with calcium, or magnesium alone, or combined with increasing pH values (3.0-7.0) resulted in augmented adsorption of HSA to Ti. No increase in adsorption was observed following pretreatment of Ti with potassium. These results point to the involvement of electrostatic interactions in the adsorption of HSA to TiO2.

Hypocalcemic tetany and metabolic alkalosis in a dialysis patient: an unusual event

The case is described of a 29-year-old man with renal failure and recurrent hyperparathyroidism who 3 weeks postparathyroidectomy developed hypocalcemic tetany because he was taking one-half the prescribed dose of calcitriol. He interpreted his symptoms as those of potassium intoxication and self-administered almost 1,500 mEq sodium bicarbonate. The increase in plasma sodium and osmolarity led to increased fluid intake, and at presentation he had an ionized calcium of 0.50 mmol/L, K 5.3 mmol/L, Na 148 mmol/L, total CO2 52.6 mmol/L, pO2 51.2 mm Hg, and pH of 7.61. He had gained 7 kg in weight. All abnormalities were corrected by dialysis, using initially a calcium-free dialyzate with extra calcium infused. The case illustrates the effect of alkalosis in reducing the amount of calcium that exists in ionized form, and it is suggested that complexing of calcium as calcium bicarbonate together with the pH change contributed to the decrease in ionized calcium. It is also an example of the hazards of treating patients who devise their own therapeutic regimens.

SOME CHARACTERISTICS OF PRIMARY HYPERPARATHYROIDISM IN VIETNAMESE IMMIGRANTS LIVING IN SOUTHERN CALIFORNIA

OBJECTIVE

To characterize primary hyperparathyroidism (PHP) in Vietnamese immigrants living in southern California and to summarize the results of treatment.

METHODS

We describe 11 patients (8 women and 3 men) with a mean age of 57.91 years who underwent follow-up from 1991 to 1995 after PHP was diagnosed. The patients had no specific complaints. Four patients had a history of kidney stones, and five had chronic hypertension. Only five patients had high levels of total serum calcium; the other six patients had normal or fluctuating levels of total serum calcium. All patients, however, had high levels of intact parathyroid hormone (PTH) and ionized calcium. Preoperatively, parathyroid imaging with technetium-99m sestamibi demonstrated persistently increased parathyroid gland uptake.

RESULTS

In all nine patients who underwent surgical treatment, an adenoma was found in the parathyroid glands; two patients refused operative intervention. The mean serum phosphate was in the low-normal range and increased postoperatively (2.70 versus 3.52 mg/dL; P<0.001). The mean serum chloride level also decreased postoperatively (104.62 versus 100.78 mEq/L; P<0.001). The ratio of chloride/phosphate decreased significantly after adenoma removal (39.44 versus 29.21; P<0.001). Six patients received calcium gluconate either alone or in combination with vitamin D supplements for hypocalcemia postoperatively. The other three patients, however--who did not receive calcium supplements postoperatively--had persistently high levels of intact PTH but normal serum Ca++ levels and subsequently were treated effectively with calcium gluconate and vitamin D.

CONCLUSION

The presence of hypercalcemia, especially Ca++, and an increased level of intact PTH establishes the diagnosis of PHP. After parathyroidectomy, the persistence of high levels of intact PTH in association with normal serum Ca++ suggested the presence of secondary hyperparathyroidism, which was treated effectively with calcium gluconate and vitamin D. These patients had the same clinical picture as other ethnic groups with PHP, but they needed either calcium alone or calcium and vitamin D supplements after parathyroidectomy because of their bone loss from prolonged PHP.

Bisphosphonates: a review of their pharmacokinetic properties

Bisphosphonates are a unique class of drugs. As a family, they are characterized pharmacologically by their ability to inhibit bone resorption, whereas, pharmacokinetically, they are classified by their similarity in absorption, distribution, and elimination. Although all bisphosphonates have similar physicochemical properties, their antiresorbing activities differ substantially. Activity is dramatically increased when the amino group is contained in the aliphatic carbon chain. For example, alendronate, an aminobisphosphonate, is approximately 700-fold more potent than etidronate, both in vitro and in vivo. In general, bisphosphonates are poorly absorbed from the gastrointestinal tract as a result of their poor lipophilicity. In vitro and in vivo studies have shown that bisphosphonates are absorbed from the gastrointestinal tract via paracellular transport. Systemically available bisphosphonates disappear very rapidly from plasma, and are partly taken up by the bone and partly excreted by the kidney. The relative contribution of these two processes to overall plasma elimination differs significantly among bisphosphonates. To date, all bisphosphonates studied show no evidence of metabolism. Renal excretion is the only route of elimination. Studies with alendronate in rats indicate that the drug is actively secreted by an uncharacterized renal transport system, and not by the anionic or cationic renal transport systems. Bisphosphonates bind preferentially to bones which have high turnover rates, and their distribution in bone is not homogeneous. After bone uptake, the bisphosphonates are liberated again only when the bone in which they are deposited is resorbed. Thus, the half-life of bisphosphonates in bone is very long, ranging among different species from 1 to 10 years, depending largely on the rate of bone turnover.

Mechanisms of myocardial depression after bolus injection of sodium bicarbonate

PURPOSE

The classic model for the effects of NaHCO3 on myocardial function predicts transient myocardial depression after an intravenous bolus of sodium bicarbonate in association with myocardial acidosis.

METHODS

Five anesthetized, paralyzed, and ventilated dogs underwent midline sternotomy. Myocardial global function was assessed by cardiac output, left ventricular (LV) dp/dt, LV end-systolic, and LV end-diastolic pressures. Regional myocardial function assessed by measuring the LV regional end-systolic, LV end-diastolic lengths, and LAD coronary blood flow. Coronary sinus, intramyocardial and arterial pH were measured as was free serum Ca++. Animals were made acidemia by infusion of 0.3 N HCl and then given a bolus of sodium bicarbonate. This produced transient depression followed by recovery of myocardial function.

RESULTS

During the depression phase there was no significant decrease in interstitial pH or an increase in A-VCO2 difference as predicted by the current model. However, there was a significant decrease in the serum free Ca++ that coincided with myocardial depression.

CONCLUSION

We could not confirm the predictions of the classic model and hypothesize that myocardial depression may be caused by decreased availability of free Ca++ of decreased Ca++ flux rather than intracellular acidosis.

Bicarbonate does not increase left ventricular contractility during L-lactic acidemia in pigs

Lactic acidosis decreases left ventricular contractility, but whether bicarbonate increases left ventricular contractility during lactic acidosis in vivo is controversial. Therefore, we measured hemodynamics and left ventricular mechanics before and after bicarbonate administration during L-lactic acid infusion in 15 anesthetized pigs. The pigs were beta-blocked and atrially paced to minimize indirect effects of acidosis on contractility. We measured mean arterial pressure, left ventricular end-diastolic pressure, thermodilution cardiac output, left ventricular pressure (Miller catheter), and left ventricular volume (three orthogonal pairs of ultrasonic crystals). Left ventricular contractility was assessed primarily using the slope (Emax) of the end-systolic pressure-volume relationship. While PCO2 was kept constant, 0.2 M L-lactic acid was infused, which reduced arterial pH to 7.05 +/- 0.06. Animals were then randomized to receive either 1 M NaHCO3 (n = 8), which increased pH to 7.45 +/- 0.11, or an equivalent amount of 1 M NaCl (n = 7). Bicarbonate decreased mean arterial pressure (105 +/- 20 to 95 +/- 39 mm Hg, p < 0.05) but did not increase cardiac output. These effects were not significantly different from the effects of saline. Bicarbonate did not significantly increase Emax (4.2 +/- 0.8 to 4.9 +/- 0.8 mm Hg/ml) and was indistinguishable from saline (5.0 +/- 0.7 to 5.2 +/- 0.7 mm Hg/ml). We conclude that bicarbonate infusion does not directly increase left ventricular contractility during lactic acidemia in pigs within this pH range.

Prolonged postischemic hyperventilation reduces acute neuronal damage after 15 min of cardiac arrest in the dog

Hyperventilation is commonly used as a constituent of antiedematous therapy after global cerebral ischemia. The effect of hyperventilation on brain functions, however, is complex, and a number of mechanisms involved remains unclear. In this study, we attempted to determine whether postischemic hyperventilation influences acute neuronal changes developing during recirculation. Two groups of dogs underwent 15 min of cardiac arrest and cardiopulmonary resuscitation with an 8 h survival. After resuscitation, in group A the internal environment was maintained in the physiological ranges. In group B the animals were artificially hyperventilated maintaining a high level of respiratory alkalosis during recirculation. Histopathological examination of the vulnerable structures was performed using the Nauta degenerating method and the argyrophilic neurons were counted. Statistically significant amelioration in group B suggests that postischemic hyperventilation may act as a neuroprotective factor.

Platelet-activating factor type activity in plasma from patients with septicemia and other diseases

The purpose of the present study was to determine whether increased levels of platelet-activating factor (PAF) type activity can be detected in plasma from patients with septicemia and other diseases. A level of PAF below 0.5 ng/mL of plasma was considered normal. We found that plasma from a patient with adverse anaphylactoidic reaction to intravenous analgetics contained 2.1 ng PAF/mL. In seven patients with septicemia, including urosepsis, endocarditis and peritonitis, and with positive blood culture, increased plasma PAF levels (1-20 ng PAF/mL) were observed. Other patients with clinical indications of septicemia had negative blood cultures and/or increased levels of C-reactive protein (CRP). Yet, in the plasma from these patients, no increased PAF levels were detected under the assay conditions used. Two patients with allergic asthma, requiring treatment with steroids, had no measurable plasma PAF. In the plasma from a patient with idiopathic thrombocytopenic purpura (ITP) only an "endogenous" inhibitor of PAF induced platelet aggregation was initially observed. In spite of this, the patient responded to treatment with the PAF antagonist WEB 2086 with a dramatic increase in platelet count (Lohmann et al., Lancet ii, 1147, 1988). Thereafter, also increased PAF levels (3.3 ng PAF/mL) were detected in plasma, although some "endogenous" inhibitor of PAF was still present. In conclusion, increased PAF levels in plasma from patients support a role of PAF in certain human disease states, such as in anaphylactoid reaction, sepsis and septic shock. The type, relevance and specificity of endogenous inhibitors of PAF deserve further study.

Effects of erythrocytes, bicarbonate, temperature and albumin on in vitro ionized calcium variations with pH

Using a heart lung machine as an in vitro model, the relation between ionized calcium (cCa2+) and pH has been shown to depend on several variables such as erythrocytes, temperature and albumin as well as the total calcium and bicarbonate concentrations. The respiratory acid-base disturbances were simulated by changing the gas flow between 1.0 and 2.41 min-1 by adding CO2, to the machine at a concentration of 0 to 17%. When pCO2 was used to alter pH, cCa2+ varied from 0.16 mmol l-1 per pH unit to 0.52 mmol l-1. The regression slope of cCa2+ on pH was made steeper by decreasing erythrocyte volume fraction and by increasing temperature and the concentrations of HCO3, calcium or albumin. The metabolic acid-base alterations were produced by HCl or NaHCO3 at a constant gas flow, cCA2+ changes per pH unit were 0.70 mmol l-1 in plasma and 1.04 mmol l-1 in whole blood. The different results found in plasma and in erythrocyte fluids may be explained by their different buffering capacity. Haemoglobin may buffer hydrogen ions, and the formation of HCO3- is catalysed by carbonic anhydrase from the red cells.

In vivo and in vitro ionized calcium variations induced by acute respiratory acid base disturbances

The effects of acute respiratory acid base changes on the ionized calcium concentration were studied in mechanically ventilated patients and compared to the results which were found using an in vitro model. In both in vivo and in vitro studies, the ionized calcium changes correlated negatively with the pH variations. The good agreement between the in vivo and in vitro investigations showed a mean ionized calcium change of 0.40 mmol/l per pH unit. At the same time, the ionized calcium changes correlated positively with the changes of plasma bicarbonate. The mean ionized calcium change was 0.01 mmol/l per mmol/l bicarbonate variation. During respiratory acid base disturbances, the ionized calcium variations due to the competitive albumin binding between hydrogen and calcium ions are buffered and blunted by the bicarbonate ions.

When is serum albumin worth measuring?

This paper critically examines the usefulness of serum albumin measurement in the light of current laboratory practice and knowledge of the pathophysiology of albumin metabolism. The main conclusions and recommendations are as follows: (i) Albumin measurement forms a limited, but useful part of the investigation of liver disease; a normal serum albumin concentration makes the diagnosis of cirrhosis unlikely, while a low level in viral hepatitis suggests either severe hepatocellular damage or other complications. (ii) Albumin measurement is essential in selecting patients for, and in determining the amount and frequency of, albumin replacement. (iii) Serum albumin concentration provides a useful indication of prognosis in myeloma. (iv) In the long-term management of patients undergoing enteral or parenteral nutrition, serum albumin concentration is one of several parameters which, together, are useful in predicting the outcome of treatment. (v) The serum albumin concentration may provide a clue to the aetiology of unexplained oedema. (vi) Serum albumin measurement is useful in indicating the level of ionised calcium and of unbound unconjugated bilirubin.

Plasma ionized calcium during paediatric anaesthesia: effects of pH and succinylcholine

Variations of plasma ionized calcium and pH were studied in 16 children anaesthetized with halothane and succinylcholine for minor surgery. During anaesthesia, a close negative correlation was noted between pH and ionized calcium. Intubation was followed by a fall of the ionized calcium concentration. A mean decrease of 0.04 mmol X L-1 was noted, without pH change. The acute elevation of carbon dioxide following extubation allowed the in vivo effects of pH on ionized calcium to be studied. For each pH unit decrease, a mean rise of 0.60 mmol X L-1 of ionized calcium was found. During the study, no significant variations of plasma total calcium concentration were observed. The variations in the hydrogen ion concentration and the administration of succinylcholine were accompanied by changes of the free calcium ion concentration, due probably to alterations in calcium binding to proteins, and perhaps to the formation of a calcium complex with anions. Our results emphasize the importance of knowledge of the pH for the interpretation of ionized calcium variations in the presence of acid-base disturbances.

Calcium and thiocyanate interactions with crosslinked albumin microcapsules: influence of the reticulation rate

Ca2+ and SCN- interactions with strongly or lightly crosslinked albumin microcapsules were studied, using 45Ca2+ for a pH range varying from 5.5 to 7.8 and 14SCN- ions for the range 2.15 to 3.0. With strongly crosslinked albumin, the Scatchard plots of equilibrium isotherms indicate a maximum number of binding sites for Ca2+ ions, when N is equal to 12 and an apparent association constant, K' is equal to 7.8 X 10(3) l/mol. For the weakly crosslinked albumin, this constant is equal to 11 X 10(3) l/mol and the variation of calcium absorption with pH has an unusual shape, with a maximum at pH 6.5. The measurement of SCN- ion absorption by lightly crosslinked microcapsules indicates a K' value of 5.4 X 10(3) l/mol and an N value of 7 for pH 2.15. These values are, respectively, 8.3 X 10(3) l/mol and 2 for pH 2.15 when using strongly crosslinked microcapsules.

Effects of physical exercise on serum calcium and parathyroid hormone

The effects of physical exercise on plasma ionized calcium, total serum calcium and parathyroid hormone (PTH) concentrations were evaluated in healthy subjects submitted to work on an ergometer bicycle. When the workload was increased stepwise there was a significant increase (P less than 0.001) in the calcium concentrations (ionized calcium from 1.13 +/- 0.03 (SD) to 1.24 +/- 0.03 mmol 1(-1) and total calcium from 2.35 +/- 0.07 to 2.48 +/- 0.07 mmol 1(-1] when the workload exceeded approximately 65% of the estimated maximum--i.e. a load that caused accumulation in blood of lactic acid. The rise in plasma ionized calcium was, therefore, presumably largely attributed to the acidosis but reduction of plasma volume and influx from extracellular sources might also have contributed. Beta blockade (with oral intake of propranolol) reduced physical capacity, shortened the duration of work and caused less acidosis. These factors were probably responsible for a smaller rise in ionized calcium during beta blockade (7 +/- 4%) than in control studies (21 +/- 5%) without medication in subjects examined during short-term maximal exercise. Long-term (1 h) steady-state work which caused fatigue without producing lactic acidosis did not affect the calcium concentrations. Despite the effects of work on calcium levels there was no discernible suppression of the PTH concentrations. This might have been due to a concomitant stimulation of PTH secretion by work.

Free ionised calcium--a critical survey

It is our aim to summarise and discuss procedures for the evaluation of the concentration of free ionised calcium in serum or plasma. Stress is laid upon the interrelations and relative validity of the most common algebraic expressions to appraise the calcium status. The multitude of formulae proposed in the literature are, by mathematical discussion, reduced to variations on a single theme. A second topic is the direct potentiometric measurement of free ionised calcium concentration. Finally we review the literature on the clinical utility of measuring or calculating the free ionised calcium concentration.

Increased sensitivity of arachidonic acid-induced platelet aggregation in the presence of carbon dioxide

The effects of carbon dioxide on citrated human platelet-rich plasma (PRP) have been studied as a means of imitating the changes in pH and PCO2 observed in inflammation and tissue fluid stasis. Adenosine diphosphate (ADP)-induced platelet aggregation was inhibited in CO2-treated PRP. In contrast, CO2-treated platelets were rendered up to eight times more sensitive to sodium arachidonate and this effect could be imitated by the addition of exogenous calcium 1 min before the addition of arachidonate. The effects of CO2 on ADP-induced and arachidonate-induced aggregation were abolished if the CO2 was allowed to disperse from treated PRP subsequently exposed to air, suggesting no permanent alteration in platelet metabolism. The increased sensitivity of arachidonate-induced aggregation with lowered pH may be a significant factor in influencing platelet behaviour in haemostasis.

Glucagon and insulin secretion during acid-base alterations

Previously, we reported that change from the normal pH of 7.4 surrounding the islet cells to 7.8 results in a decreased B-cell response to 16.6 mM glucose, 10 mM arginine or 400 micrograms/ml tolbutamide. In the present report we studied the effect of modifications in the extracellular pH on glucose- and arginine-induced glucagon and insulin secretion by the perfused rat pancreas. It was found that at pH 7.8, arginine-induced glucagon secretion was significantly greater than at pH 7.4. On the other hand, the switch from pH 7.4 to 7.8 in a pancreas already stimulated by either low glucose or arginine, produced fast and transient glucagon release. Sequential extracellular pH changes from 7.4 to 7.8 and back to 7.4 in the presence of 8.3 mM glucose and a 5 mM arginine stimulus demonstrated that A- and B-cells rapidly modify their secretion in response to extracellular alkalosis in opposite directions. While glucagon output was enhanced (mean secretory rates at pH 7.4, 0.692 +/- 0.042 ng/min and 0.948 +/- 0.57 at pH 7.8), insulin secretion was clearly reduced (72.6 +/- 6.2 ng/min and 35.7 +/- 2.8 ng/min at pH 7.4 and 7.8, respectively). The above observations, together with our previously reported data, indicate that extracellular pH plays an important role in the regulation of glucagon and insulin release. Particularly, extracellular alkalosis enhances A-cell response to 2.3 mM glucose and 5 mM arginine while partially inhibiting B-cell secretion in the perfused rat pancreas.

A calcium hypothesis of antidepressant action

The biogenic amine hypothesis of affective disorders has served as a valuable model for investigations concerning the mechanism of action of antidepressant drugs. Despite numerous publications on the subject, the manner in which tricyclic antidepressants elicit their therapeutic effect remains unknown. Recent findings which involve tricyclic antidepressant interactions with thyroid hormone, along with an appraisal of the older literature concerned with dyscalcemias and affective disorders, provides the basis for an hypothesis featuring a role for calcium in mediating antidepressant responses.

Human serum albumin as an allosteric two-state protein. Evidence from effects of calcium and warfarin on proton binding behaviour

The proton binding of human serum albumin, and the influence on it of Ca2+ and warfarin (3-(alpha-acetonylbenzyl)-4-hydroxycoumarin), has been studied in the pH region 6 to 9, in order to get more information on the conformational change occurring in serum albumin around neutral pH, the so-called N-B transition. Some of the results for human serum albumin are compared with bovine serum albumin. A two-state model describing this transition is presented. In this model the two states are assumed to be the N state (found at low pH) and the B state (found at high pH). The ligand to be considered is the proton, having the highest affinity for the N conformation. An allosteric constant, L, governs the equilibrium between the two states. Both Ca2+ and warfarin can act as allosteric effectors, thereby increasing L. The model is used to describe results such as: (a) the cooperativity in proton binding, most clearly observable when Ca2+ is present, and the difficulty of measuring experimentally this cooperativity; (b) the different number of protons bound when Ca2+ is present or absent; (c) the fraction of protein found in one of the two conformations; (d) the correspondence between the increase of L due to addition of Ca2+ or warfarin, as predicted from model calculations, and the experimentally found increase of L.

Plasma ionized calcium in the critically ill on total parenteral nutrition

Eight patients were monitored three times daily for 3 consecutive days. Plasma calcium fluctuated slightly, whereas phosphate varied more and in two patients fell below 0.08 mmol/I. Necessary calcium and phosphate supply for adults was estimated to be 0.15 and 0.25 mmol per kg body mass per day, respectively. Plasma ionized calcium could be estimated form total calcium, albumin and pH with a standard deviation of 0.05 mmol/l. This is 5 times higher than by direct measurement with a new combined pH-pCa electrode system.