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Lukomskyj AO, Partyka CL. Severe Multifactorial Metabolic Alkalosis in the Emergency Department: A Case Report. J Emerg Med 2024; 66:e33-e37. [PMID: 37867035 DOI: 10.1016/j.jemermed.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/14/2023] [Accepted: 08/10/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Metabolic alkalosis is an uncommon clinical entity resulting from a wide variety of underlying etiologies including gastrointestinal, renal, endocrine, and metabolic causes. It is a typically clinically silent condition; however, severe cases can be life-threatening, mandating both a systematic investigative approach and an early aggressive management strategy. CASE REPORT We present a case of a 58-year-old man with severe, multifactorial metabolic alkalosis (pH 7.72, HCO3- 42 mmol/L, pCO2 31 mm Hg) resulting from refractory vomiting, severe hypokalemia (2.0 mmol/L), and hypoalbuminemia (albumin 20 g/L). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe metabolic alkalosis is associated with significant morbidity and mortality. Clinicians need to be aware of the potential underlying causes in these cases, as well as how to delineate between chloride- and non-chloride-depleted states, which dictates initial treatment. We provide a pragmatic summary of the evaluation, pertinent investigations, and early management of these cases.
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Affiliation(s)
- Alissa O Lukomskyj
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Christopher L Partyka
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Aeromedical Operations, NSW Ambulance, Bankstown Airport, New South Wales, Australia
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2
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Terlizzi V, Padoan R, Leonetti G, Vitullo P, Tosco A, Taccetti G, Fevola C, Ficili F, Pepe A, Poli P, Claut L, Daccò V, Salvatore D. Cystic fibrosis and CFTR-related disorder with electrolyte imbalance at diagnosis: clinical features and outcome in an Italian cohort. Eur J Pediatr 2023; 182:5275-5283. [PMID: 37725210 DOI: 10.1007/s00431-023-05193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/21/2023]
Abstract
There is limited information available on the clinical data, sweat test trends, and outcomes of individuals with cystic fibrosis (CF) who present with an isolated episode of hypoelectrolytemia with metabolic alkalosis (HMA). This study describes a cohort of Italian individuals with HMA as presenting symptom. The study is a retrospective multicenter analysis of individuals who presented with HMA as an initial symptom and was followed at 8 Italian CF Centers, from March 1988 to March 2022. Demographic, clinical, microbiological, biochemical, and genetic data were extracted from local health records. Ninety-three individuals were enrolled in the study. At first evaluation, 82 (88.2%) were diagnosed with CF, and 11 received a CFTR-Related Disorder (CFTR-RD) diagnostic label. Twenty-three (85.1%) out of the 27 subjects who underwent CF neonatal screening (NBS) resulted falsely negative. After a mean observational period of 11.5 years, most of subjects had a mild pulmonary phenotype, pancreatic sufficiency, and rarely CF-related complications. Four CFTR-RD changed to a CF diagnosis during the study period, resulting in 86 (92.4%) subjects classified as CF. CONCLUSIONS Most CF patients presenting with isolated HMA have a mild course of disease and rarely CF-related complications. WHAT IS KNOWN • Isolated episode of hypoelectrolytemia with metabolic alkalosis is a well-known onset symptom of Cystic Fibrosis in infancy. • There is limited information available on the clinical data and outcomes of individuals with Cystic Fibrosis who present with electrolyte imbalance at diagnosis. WHAT IS NEW • Most patients with Cystic Fibrosis presenting with isolated hypoelectrolytemia and metabolic alkalosis have a mild course of disease and rarely CF-related complications. • Electrolyte imbalance at diagnosis of Cystic Fibrosis is a common symptom in children not screened for CF at birth, or in those who received a false negative result from newborn screening.
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Affiliation(s)
- Vito Terlizzi
- Department of Paediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy.
| | - Rita Padoan
- Scientific Board, Italian Cystic Fibrosis Registry, Rome, Italy
| | - Giuseppina Leonetti
- Pediatric Cystic Fibrosis Centre, Azienda Universitaria Ospedaliera Consorziale Policlinico, Bari, Italy
| | - Pamela Vitullo
- Cystic Fibrosis Support Center, Ospedale G. Tatarella di Cerignola, Cerignola, Italy
| | - Antonella Tosco
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - Giovanni Taccetti
- Department of Paediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Cristina Fevola
- Department of Paediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Francesca Ficili
- Cystic Fibrosis Center, Ospedale Giovanni Di Cristina, Palermo, Italy
| | - Angela Pepe
- Cystic Fibrosis Center, Hospital San Carlo, Potenza, Italy
| | - Piercarlo Poli
- Department of Pediatrics, Cystic Fibrosis Regional Support Center, University of Brescia, ASST Spedali Civili Brescia, Brescia, Italy
| | - Laura Claut
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Valeria Daccò
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Donatello Salvatore
- Scientific Board, Italian Cystic Fibrosis Registry, Rome, Italy
- Cystic Fibrosis Center, Hospital San Carlo, Potenza, Italy
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3
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van den Bunder FAIM, Stevens MF, van Woensel JBM, van de Brug T, van Heurn LWE, Derikx JPM. Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis. Eur J Pediatr Surg 2023; 33:485-492. [PMID: 36417975 DOI: 10.1055/a-1984-9803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Normalization of metabolic alkalosis is an important pillar in the treatment of infantile hypertrophic pyloric stenosis (IHPS) because uncorrected metabolic alkalosis may lead to perioperative respiratory events. However, the evidence on the incidence of respiratory events is limited. We aimed to study the incidence of peroperative hypoxemia and postoperative respiratory events in infants undergoing pyloromyotomy and the potential role of metabolic alkalosis. MATERIALS AND METHODS We retrospectively reviewed all patients undergoing pyloromyotomy between 2007 and 2017. All infants received intravenous fluids preoperatively to correct metabolic abnormalities close to normal. We assessed the incidence of perioperative hypoxemia (defined as oxygen saturation [SpO2] < 90% for > 1min) and postoperative respiratory events. Additionally, the incidence of difficult intubations was evaluated. We performed a multivariate logistic regression analysis to evaluate the association between admission or preoperative serum pH values, bicarbonate or chloride, and peri- and postoperative hypoxemia or respiratory events. RESULTS Of 406 included infants, 208 (51%) developed 1 or more episodes of hypoxemia during the perioperative period, of whom 130 (32%) experienced it during induction, 43 (11%) intraoperatively, and 112 (28%) during emergence. About 7.5% of the infants had a difficult intubation and 17 required more than 3 attempts by a pediatric anesthesiologist. Three patients developed respiratory insufficiency and 95 postoperative respiratory events were noticed. We did not find a clinically meaningful association between laboratory values reflecting metabolic alkalosis and respiratory events. CONCLUSIONS IHPS frequently leads to peri- and postoperative hypoxemia or respiratory events and high incidence of difficult tracheal intubations. Preoperative pH, bicarbonate, and chloride were bad predictors of respiratory events.
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Affiliation(s)
- Fenne A I M van den Bunder
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Markus F Stevens
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Job B M van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Tim van de Brug
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Joep P M Derikx
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
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Palmer BF, Clegg DJ. Respiratory Acidosis and Respiratory Alkalosis: Core Curriculum 2023. Am J Kidney Dis 2023; 82:347-359. [PMID: 37341662 DOI: 10.1053/j.ajkd.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/05/2023] [Indexed: 06/22/2023]
Abstract
The respiratory system plays an integral part in maintaining acid-base homeostasis. Normal ventilation participates in the maintenance of an open buffer system, allowing for excretion of CO2 produced from the interaction of nonvolatile acids and bicarbonate. Quantitatively of much greater importance is the excretion of CO2 derived from volatile acids produced from the complete oxidation of fat and carbohydrate. A primary increase in CO2 tension of body fluids is the cause of respiratory acidosis and develops most commonly from one or more of the following: (1) disorders affecting gas exchange across the pulmonary capillary, (2) disorders of the chest wall and the respiratory muscles, and/or (3) inhibition of the medullary respiratory center. Respiratory alkalosis or primary hypocapnia is most commonly caused by disorders that increase alveolar ventilation and is defined by an arterial partial pressure of CO2 <35 mm Hg with subsequent alkalization of body fluids. Both disorders can lead to life-threatening complications, making it of paramount importance for the clinician to have a thorough understanding of the cause and treatment of these acid-base disturbances.
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Affiliation(s)
- Biff F Palmer
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Deborah J Clegg
- Office of Research, Texas Tech Health Sciences Center, El Paso, Texas
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Sahu U, Trivedi T, Gupta R. Milk-Alkali Syndrome: A Century-old Cause of Hypercalcemia Requires the Addition of Venous Blood Gas in Hypercalcemia Workup. J Assoc Physicians India 2023; 71:104-105. [PMID: 38700310 DOI: 10.59556/japi.71.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
The Milk-Alkali syndrome (MAS) is identified by the triad of high serum levels of calcium, metabolic alkalosis, and acute kidney injury, usually caused by consuming excessive amounts of calcium and absorbable alkali. If not treated promptly, the syndrome can result in rapid hypercalcemia, acute renal failure, and metastatic calcification. Notably, an increasing number of cases of MAS have been observed, potentially due to the rampant use of calcium-based over-the-counter supplements for the prevention and treatment of osteoporosis in postmenopausal women. Herein, we report a case of severe hypercalcemia due to prolonged intake of calcium carbonate supplements in the absence of any alkali. The case report highlights the importance of including venous blood gas (VBG) analysis as a part of the workup for hypercalcemia, as metabolic alkalosis can help clinch the diagnosis of MAS in the setting of severe hypercalcemia. How to cite this article: Sahu U, Trivedi T, Gupta R. Milk-Alkali Syndrome: A Century-old Cause of Hypercalcemia Requires the Addition of Venous Blood Gas in Hypercalcemia Workup. J Assoc Physicians India 2023;71(9):104-105.
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Affiliation(s)
- Utsav Sahu
- Associate Consultant, Department of Medicine, Pentamed Hospital, Delhi, India, Corresponding Author
| | - Tamal Trivedi
- Associate Consultant, Department of Medicine, Pentamed Hospital, Delhi, India
| | - Rajesh Gupta
- Senior Consultant and Head, Department of Medicine, Pentamed Hospital, Delhi, India
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Leventoğlu E, Kenan BU, Çakır EP, Hocoğlu Zİ, Eyüboğlu TŞ, Büyükkaragöz B, Aslan AT, Söylemezoğlu O. Chronic cough in an adolescent with infantile onset of hypokalemic hypochloremic metabolic alkalosis: Questions. Pediatr Nephrol 2023; 38:1027-1028. [PMID: 35723734 DOI: 10.1007/s00467-022-05641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Emre Leventoğlu
- Faculty of Medicine, Department of Pediatric Nephrology, Gazi University, Ankara, Turkey.
| | - Bahriye Uzun Kenan
- Faculty of Medicine, Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
| | - Eylül Pınar Çakır
- Faculty of Medicine, Department of Pediatric Pulmonology, Gazi University, Ankara, Turkey
| | - Zeynep İlkşen Hocoğlu
- Faculty of Medicine, Department of Pediatric Pulmonology, Gazi University, Ankara, Turkey
| | | | - Bahar Büyükkaragöz
- Faculty of Medicine, Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
| | - Ayşe Tana Aslan
- Faculty of Medicine, Department of Pediatric Pulmonology, Gazi University, Ankara, Turkey
| | - Oğuz Söylemezoğlu
- Faculty of Medicine, Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
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Ghumman GM, Haider M, Raffay EA, Cheema HA, Yousaf A. Hypercalcemia-induced hypokalemic metabolic alkalosis with hypophosphatemia in a multiple myeloma patient: lessons for the clinical nephrologist. J Nephrol 2023; 36:315-317. [PMID: 36269493 DOI: 10.1007/s40620-022-01467-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/07/2022] [Indexed: 10/24/2022]
Affiliation(s)
| | - Marjan Haider
- Internal Medicine Resident, St. Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | | | | | - Amman Yousaf
- Internal Medicine Resident, McLaren Flint, Flint, MI, USA
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8
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Abstract
Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non-gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non-gap acidoses result from disorders of renal tubular H + transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO 2 can be considered.
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Affiliation(s)
- Anand Achanti
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Harold M. Szerlip
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
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La Bella S, Fiorentino R, Carabotta M, Lizzi M, Rosato T, Trotta D, Aricò M. A difficult case of hyponatremic and hypokalemic metabolic alkalosis: Questions. Pediatr Nephrol 2022; 37:3063-3064. [PMID: 35579759 DOI: 10.1007/s00467-022-05596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
Affiliation(s)
- Saverio La Bella
- Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy.
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy.
| | - Riccardo Fiorentino
- Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
| | - Maura Carabotta
- Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
| | - Mauro Lizzi
- Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
| | - Teresa Rosato
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
| | - Daniela Trotta
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
| | - Maurizio Aricò
- Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy
- Department of Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale, Pescara, Italy
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10
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Do C, Vasquez PC, Soleimani M. Metabolic Alkalosis Pathogenesis, Diagnosis, and Treatment: Core Curriculum 2022. Am J Kidney Dis 2022; 80:536-551. [PMID: 35525634 PMCID: PMC10947768 DOI: 10.1053/j.ajkd.2021.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/03/2021] [Indexed: 02/02/2023]
Abstract
Metabolic alkalosis is a widespread acid-base disturbance, especially in hospitalized patients. It is characterized by the primary elevation of serum bicarbonate and arterial pH, along with a compensatory increase in Pco2 consequent to adaptive hypoventilation. The pathogenesis of metabolic alkalosis involves either a loss of fixed acid or a net accumulation of bicarbonate within the extracellular fluid. The loss of acid may be via the gastrointestinal tract or the kidney, whereas the sources of excess alkali may be via oral or parenteral alkali intake. Severe metabolic alkalosis in critically ill patients-arterial blood pH of 7.55 or higher-is associated with significantly increased mortality rate. The kidney is equipped with sophisticated mechanisms to avert the generation or the persistence (maintenance) of metabolic alkalosis by enhancing bicarbonate excretion. These mechanisms include increased filtration as well as decreased absorption and enhanced secretion of bicarbonate by specialized transporters in specific nephron segments. Factors that interfere with these mechanisms will impair the ability of the kidney to eliminate excess bicarbonate, therefore promoting the generation or impairing the correction of metabolic alkalosis. These factors include volume contraction, low glomerular filtration rate, potassium deficiency, hypochloremia, aldosterone excess, and elevated arterial carbon dioxide. Major clinical states are associated with metabolic alkalosis, including vomiting, aldosterone or cortisol excess, licorice ingestion, chloruretic diuretics, excess calcium alkali ingestion, and genetic diseases such as Bartter syndrome, Gitelman syndrome, and cystic fibrosis. In this installment in the AJKD Core Curriculum in Nephrology, we will review the pathogenesis of metabolic alkalosis; appraise the precipitating events; and discuss clinical presentations, diagnoses, and treatments of metabolic alkalosis.
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Affiliation(s)
- Catherine Do
- Division of Nephrology, University of New Mexico, and Veterans Administration Medical Center, Albuquerque, New Mexico
| | - Pamela C Vasquez
- Division of Nephrology, University of New Mexico, and Veterans Administration Medical Center, Albuquerque, New Mexico
| | - Manoocher Soleimani
- Division of Nephrology, Department of Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.
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Sharma N, Ehlayel AM. Metabolic alkalosis in peritoneal dialysis - beyond the obvious: Answers. Pediatr Nephrol 2022; 37:2075-2077. [PMID: 35275278 DOI: 10.1007/s00467-022-05498-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Neha Sharma
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA
| | - Abdulla M Ehlayel
- Division of Nephrology, Children's Hospital of New Orleans, 200 Henry Clay Ave, New Orleans, LA, 70118, USA.
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12
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Kermond R, Carter S, Quinlan C. A child presents with acute kidney injury, alkalosis and hypercalcaemia-a new-age cause for a historical syndrome: Answers. Pediatr Nephrol 2022; 37:1807-1810. [PMID: 35166912 PMCID: PMC8852858 DOI: 10.1007/s00467-022-05465-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Rachael Kermond
- Nephrology Department, Children's Hospital Westmead, Sydney Children's Hospital Network, Sydney, NSW, Australia.
| | - Simon Carter
- Department of Pediatric Nephrology, Royal Children's Hospital, Melbourne, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Catherine Quinlan
- Department of Pediatric Nephrology, Royal Children's Hospital, Melbourne, Australia
- Department of Kidney Regeneration, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
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13
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Kermond R, Carter S, Quinlan C. A child presents with acute kidney injury, alkalosis and hypercalcaemia-a new-age cause for a historical syndrome: Questions. Pediatr Nephrol 2022; 37:1805-1806. [PMID: 35166909 DOI: 10.1007/s00467-022-05454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Rachael Kermond
- Nephrology Department, Children's Hospital Westmead, Sydney Children's Hospital Network, Sydney, NSW, Australia.
| | - Simon Carter
- Department of Pediatric Nephrology, Royal Children's Hospital, Melbourne, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Catherine Quinlan
- Department of Pediatric Nephrology, Royal Children's Hospital, Melbourne, Australia
- Department of Kidney Regeneration, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
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14
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Tzvi-Behr S, Bnaya A, Becker-Cohen R, Rinat C, Weinbrand-Goichberg J, Choshen S, Shavit L, Frishberg Y, Ben-Shalom E. Metabolic alkalosis in infants treated with peritoneal dialysis. Pediatr Nephrol 2022; 37:1889-1895. [PMID: 35039929 DOI: 10.1007/s00467-021-05344-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acid-base balance is maintained by kidney excretion of titratable acids and bicarbonate reabsorption. Metabolic alkalosis is uncommon in dialysis-treated patients. The aim of this retrospective study was to assess the rate of metabolic alkalosis in pediatric patients treated with peritoneal dialysis. METHODS Medical records of children treated with peritoneal dialysis in Shaare Zedek Medical Center from January 2000 to June 2021 were reviewed and compared with young adults currently treated with peritoneal dialysis. Demographic, clinical, and peritoneal dialysis characteristics were extracted from the medical records. RESULTS Thirty chronic peritoneal dialysis patients were included in our study, seven under 2 years, 13 between 2 and 18 years, and 10 adults. 90.3% of the measurements in infants showed metabolic alkalosis compared to 32.3% in the 2-18-year group and none in the adult group. Higher size-adjusted daily exchange volume, lack of urine output, and high lactate-containing dialysate were associated with metabolic alkalosis. Alkalosis was not explained by vomiting, diuretic therapy, or carbonate-containing medications. High transport membrane, low dietary protein, and malnutrition, all previously reported explanations for metabolic alkalosis, were not found in our study. CONCLUSIONS Metabolic alkalosis is common in infants treated with peritoneal dialysis as opposed to older children and adults. High lactate-containing dialysate is a possible explanation. Higher size-adjusted daily dialysate exchange volume, which may reflect higher bicarbonate absorption, is another independent predictor of alkalosis. Acid-base status should be closely followed in infants, and using a dialysis solution with lower bicarbonate or lactate level should be considered. A higher resolution version of the graphical abstract is available as Supplementary Information.
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Affiliation(s)
- Shimrit Tzvi-Behr
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Alon Bnaya
- Nephrology unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rachel Becker-Cohen
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Choni Rinat
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Sapir Choshen
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Linda Shavit
- Nephrology unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yaacov Frishberg
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Efrat Ben-Shalom
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
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15
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Matsuura K, Yoshida T, Uehara T, Yamada S, Yotsuida H, Hasegawa M, Katayose S, Yamada K, Yaginuma Y. Metabolic alkalosis following mitral valvuloplasty in a dog with preoperative acute kidney injury. J Am Vet Med Assoc 2021; 259:1332-1336. [PMID: 34727063 DOI: 10.2460/javma.20.09.0519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION An 11-year-old sexually intact male Shih Tzu diagnosed with acute kidney injury and left-sided congestive heart failure that had nonelective mitral valve surgery. CLINICAL FINDINGS Metabolic alkalosis developed postoperatively, and plasma bicarbonate concentration peaked 2 days after surgery (40.2 mmol/L; pH, 7.550). TREATMENT AND OUTCOME Acetazolamide administration increased the urinary excretion of bicarbonate and contributed to the improvement of the dog's acid-base status and oxygenation capacity. Metabolic alkalosis persisted for 4 days after surgery, and no treatment was required after resolution. Plasma urea nitrogen and creatinine concentrations normalized 2 days after surgery. CLINICAL RELEVANCE Severe metabolic alkalosis can occur as a complication following mitral valve surgery. Acetazolamide may be suitable for the treatment of severe metabolic alkalosis.
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Shah NZ, Malik S, Sathyapalan T, Mohammed K. Refractory hypokalaemia and hypertension with metabolic alkalosis: an acute presentation of Cushing's disease secondary to a pituitary macroadenoma. BMJ Case Rep 2021; 14:e244850. [PMID: 34446523 PMCID: PMC8395277 DOI: 10.1136/bcr-2021-244850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/03/2022] Open
Abstract
A 68-year-old woman presented with right arm cellulitis, not responsive to oral antibiotics. Intravenous antibiotics were commenced, and an ultrasound scan confirmed a collection that was surgically drained. She developed refractory hypokalaemia with normal magnesium, no gastrointestinal losses and no iatrogenic cause. She was hypertensive, hyperglycaemic, alkalotic, clinically obese with proximal myopathy and skin bruising. These clinical findings and refractory hypokalaemic hypertension with metabolic alkalosis raised a suspicion of Cushing's syndrome (CS). 24-hour urinary free cortisol (24 hours) was grossly raised on two occasions. The adrenocorticotropic hormone (ACTH) was significantly raised at 154 ng/L, confirming ACTH-dependant CS. A CT scan of the thorax, abdomen and pelvis excluded an ectopic source of hypercortisolaemia. MRI pituitary revealed an invasive macroadenoma. Treatment with endoscopic debulking resulted in the resolution of hypokalaemia and metabolic alkalosis with significant improvement in hyperglycaemia and hypertension.
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Affiliation(s)
- Najeeb Zaheer Shah
- Diabetes and Endocrinology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Department of Academic Diabetes, Endocrinology and Metabolism, University of Hull, Hull, UK
| | - Shah Malik
- Diabetes and Endocrinology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Thozhukat Sathyapalan
- Diabetes and Endocrinology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Department of Academic Diabetes, Endocrinology and Metabolism, University of Hull, Hull, UK
| | - Kamrudeen Mohammed
- Diabetes and Endocrinology, Hull University Teaching Hospitals NHS Trust, Hull, UK
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17
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Hoenig MP, Lecker SH. Trust the Patient: An Unusual Case of Metabolic Alkalosis. Clin J Am Soc Nephrol 2021; 16:800-802. [PMID: 33727222 PMCID: PMC8259474 DOI: 10.2215/cjn.18031120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Melanie Paige Hoenig
- Renal Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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18
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van den Bunder FAIM, van Woensel JBM, Stevens MF, van de Brug T, van Heurn LWE, Derikx JPM. Respiratory problems owing to severe metabolic alkalosis in infants presenting with hypertrophic pyloric stenosis. J Pediatr Surg 2020; 55:2772-2776. [PMID: 32641249 DOI: 10.1016/j.jpedsurg.2020.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Uncorrected metabolic alkalosis in infantile hypertrophic pyloric stenosis (IHPS) could lead to perioperative apnea. However, the precise incidence of preoperative respiratory problems and the association with metabolic alkalosis are unknown. Therefore, we aimed to determine the incidence of preoperative respiratory problems in IHPS and to assess the association with metabolic alkalosis. METHODS We retrospectively reviewed all patients diagnosed with IHPS during 2007-2017. Respiratory problems were classified as present or absent. With multivariate logistic regression we analyzed the association between bicarbonate and respiratory problems, corrected for gestational age and birth weight. RESULTS We included 459 infants, of whom 23 developed preoperative respiratory problems (5.0%). Infants with preoperative respiratory problems were more often female (43.5% vs. 13.3% p = 0.001) and had significantly higher median serum levels of bicarbonate (32.0 mmol/L vs. 30.0 mmol/L), base excess (6.5 mmol/L vs. 5.3 mmol/L) and pCO2 (6.4 kPa vs. 5.9 kPa), compared to infants without respiratory problems. Multivariate analysis of serum bicarbonate and presence of respiratory problems showed an OR of 2.18 per 10 mmol/L (95% CI 1.21-4.71) (p = 0.009). The optimal bicarbonate cutoff point was 25.7 mmol/L (sensitivity 100%, specificity 13.4%). CONCLUSION IHPS with metabolic alkalosis potentially results in preoperative respiratory problems. A lower bicarbonate target before surgery might be recommended and respiratory monitoring should be considered. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Fenne A I M van den Bunder
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, The Netherlands.
| | - Job B M van Woensel
- Paediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Markus F Stevens
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Tim van de Brug
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - L W Ernest van Heurn
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, The Netherlands
| | - Joep P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, The Netherlands
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Rood J, Davids R, Le Roux A, Du Plessis M, Parker A, Allwood BW, Prozesky HW, Koegelenberg CFN, Taljaard JJ. Metabolic alkalosis in hospitalised COVID-19 patients: A window to the pathogenesis? S Afr Med J 2020; 110:13109. [PMID: 33403973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 06/12/2023] Open
Affiliation(s)
- J Rood
- Department of Medicine, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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20
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Abstract
RATIONALE The typical clinical presentations of patients with primary aldosteronism (PA) include generalized weakness, fatigue, high blood pressure, and potassium deficiency. However, normotensive PA is rare. Therefore, an atypical presentation of normal blood pressure is a challenge for the diagnosis and treatment of PA. PATIENT CONCERNS A 43-year-old, thin, and tall woman (body mass index, 18.6 kg/m) with generalized weakness for 1 day presented to our emergency department, where hypokalemia was a significant finding. The initial diagnosis was anorexia nervosa with the evidence of renal potassium wasting with low urinary sodium and chloride levels, metabolic alkalosis, normal blood pressure, and low body mass index. However, neither vomiting features nor other specific induced vomiting features were noted. DIAGNOSES The laboratory examination revealed high plasma aldosterone level, low plasma renin activity, and extremely high aldosterone-to-renin ratio indicating the diagnosis of PA, confirmed via adrenal computed tomography. INTERVENTIONS Surgical adrenalectomy was performed. Pathological diagnosis was a benign cortical adenoma. OUTCOMES Patient's serum potassium level and hormonal status became normalized after surgical removal of adrenal adenoma. She fully recovered without any further sequelae. LESSONS It is too early to rule out PA based on the presence of normal blood pressure in a patient with metabolic alkalosis and renal wasting hypokalemia. Moreover, PA should be considered in a normotensive patient with an unknown hypokalemic etiology to avoid delayed diagnosis and treatment.
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Affiliation(s)
- Yen-Chu Huang
- Division of General Medicine, Department of Internal Medicine
| | - Ming-Hsien Tsai
- Division of General Medicine, Department of Internal Medicine
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan (ROC)
| | - Yu-Wei Fang
- Division of General Medicine, Department of Internal Medicine
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan (ROC)
| | - Mei-Lan Tu
- Division of General Medicine, Department of Internal Medicine
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital
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21
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Kuroya S, Yazawa M, Shibagaki Y, Tominaga N. Calcium-Alkali Syndrome Associated with Hypoparathyroidism Following Total Thyroidectomy. Am J Nephrol 2020; 51:160-167. [PMID: 31968342 DOI: 10.1159/000505718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with permanent postsurgical hypoparathyroidism, a complication of total thyroidectomy, often require high calcium supplementation with vitamin D to maintain serum calcium levels. The epidemiology of calcium-alkali syndrome (CAS) in patients with hypoparathyroidism after total thyroidectomy remains unclear. This study aimed to investigate the incidence of hypercalcemia, renal impairment, metabolic alkalosis, and CAS in patients treated for presumed hypoparathyroidism after total thyroidectomy. METHODS Twenty-seven patients with neck cancers who underwent total thyroidectomy without parathyroid autotransplantation between January 2010 and October 2013 at our hospital were consecutively included. All patients received calcium lactate and alfacalcidol for postsurgical hypocalcemia. We defined hypercalcemia as a corrected serum calcium level (cCa) ≥10.5 mg/dL, metabolic alkalosis as a difference in serum sodium and serum chloride ([sNa-sCl]) ≥39 mEq/L, and renal impairment as a ≥50% increase in serum creatine and/or ≥35% decrease in estimated glomerular filtration rate (eGFR) compared to baseline. RESULTS cCa peaked (11.1 ± 1.5 mg/dL) at a median of 326 days (interquartile range 78-869) after surgery. At peak cCa, [sNa-sCl] was significantly higher (p < 0.01), and eGFR was significantly lower (p < 0.01) than that at baseline. Fifteen patients (55.6%) had hypercalcemia, 19 (70.3%) had alkalosis, 12 (44.4%) had renal impairment, and 9 (33.3%) had CAS. Patients with CAS (mean age 67.1 ± 10.8 years) were older than those without CAS (56.7 ± 13.6 years, p = 0.06). The mean dose of alfacalcidol in the CAS group (3.1 ± 1.2 μg/day) was significantly larger than that in the non-CAS group (2.1 ± 1.0 μg/day, p = 0.03). CONCLUSIONS This retrospective study reveals the high incidence of CAS in patients with hypoparathyroidism after total thyroidectomy. Furthermore, these findings suggest that the serum calcium level, acid-base balance, and renal function should be closely monitored in patients with postsurgical hypoparathyroidism who receive large doses of active vitamin D.
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Affiliation(s)
- Sayaka Kuroya
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan,
- Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kanagawa, Japan,
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Affiliation(s)
- Kritika Agrawal
- Department of Onco-Anaesthesia and Palliative Care, Dr. B.R.A. IRCH, AIIMS, Delhi, India
| | - Satyajit Majhi
- Department of Anaesthesiology, Max Super Speciality Hospital, Saket, Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Care, Dr. B.R.A. IRCH, AIIMS, Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Care, Dr. B.R.A. IRCH, AIIMS, Delhi, India
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23
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Etemadi TR, Bosselmann HS. [Hypercalcaemia due to the milk-alkali syndrome]. Ugeskr Laeger 2018; 180:V06170499. [PMID: 29465034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This case report is about an 87-year-old woman with Alzheimer's disease and the milk-alkali syndrome, who took calcium carbonate as osteoporosis prophylaxis. We describe, how the milk-alkali syndrome can result in a triad of hypercalcaemia, metabolic alkalosis, and renal insufficiency. The syndrome is now the third most common cause of hypercalcaemia because of the use of calcium carbonate in osteoporosis prophylaxis and treatment, and the syndrome should be considered in patients with hypercalcaemia, as it may result in permanent renal impairment.
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Bastug F, Nalcacioglu H, Ozaltin F, Korkmaz E, Yel S. Nephropathic Cystinosis Mimicking Bartter Syndrome: a Novel Mutation. Iran J Kidney Dis 2018; 12:61-63. [PMID: 29421779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/20/2017] [Accepted: 09/24/2017] [Indexed: 06/08/2023]
Abstract
Cystinosis is a rare autosomal recessive disorder resulting from defective lysosomal transport of cystine due to mutations in the cystinosin lysosomal cystine transporter (CTNS) gene. The clinical phenotype of nephropathic cystinosis is characterized by renal tubular Fanconi syndrome and development of end-stage renal disease during the first decade. Although metabolic acidosis is the classically prominent finding of the disease, a few cases may present with hypokalemic metabolic alkalosis mimicking Bartter syndrome. Bartter-like presentation may lead to delay in diagnosis and initiation of specific treatment for cystinosis. We report a case of a 6-year-old girl initially presenting with the features of Bartter syndrome that was diagnosed 2 years later with nephropathic cystinosis and a novel CTNS mutation.
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Affiliation(s)
| | - Hulya Nalcacioglu
- Kayseri Education and Research Hospital, Department of Pediatric Nephrology, Kayseri, Turkey.
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25
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Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
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Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
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26
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Galešić K, Horvatić I, Ilić M, Ćuk M, Crnogorac M, Ljubanović DG. [HYPOKALEMIC METABOLIC ALKALOSIS – A REPORT OF SIX CASES]. Lijec Vjesn 2016; 138:260-265. [PMID: 30148552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In this article six patients with hypokalemic metabolic alkalosis, classified as Bartter or Gitelman syndrome are presented. Both syndromes result from different gene mutation inducing impaired function of the transporters involved in sodium, chloride and potassium reapsorption in thick ascending limb of the loop of Henle and distal convoluted tubules. These syndromes typically present with hypokalemia, metabolic alkalosis, hyperreninemic hyperaldosteronism without hypertension, polyuria and muscle weakness. Other clinical characteristics may vary considerably, depending on the gene expression. Correct diagnosis is only possible using expensive and not-routinely available genetic testing. Routine laboratory tests, especially those considering serum and urine electrolytes, can help in recognizing these syndromes and therefore in timely beginning of treatment. The most important distinctive laboratory findings are serum magnesium concentration and urine calcium excretion. In Bartter syndrome typically there is hypercalciuria with or without hypomagnesemia, while in Gitelman syndrome typical findings are hypocalciuria and hypomagnesemia. Recognizing and treating these patients is important due to possible increased morbidity and mortality induced by severe electrolyte imbalance.
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Villa-Bellosta R, González-Parra E, Egido J. Alkalosis and Dialytic Clearance of Phosphate Increases Phosphatase Activity: A Hidden Consequence of Hemodialysis. PLoS One 2016; 11:e0159858. [PMID: 27454315 PMCID: PMC4959680 DOI: 10.1371/journal.pone.0159858] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/08/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Extracellular pyrophosphate is a potent endogenous inhibitor of vascular calcification, which is degraded by alkaline phosphatase (ALP) and generated by hydrolysis of ATP via ectonucleotide pyrophosphatase/phosphodiesterase 1 (eNPP1). ALP activity (as routinely measured in clinical practice) represents the maximal activity (in ideal conditions), but not the real activity (in normal or physiological conditions). For the first time, the present study investigated extracellular pyrophosphate metabolism during hemodialysis sessions (including its synthesis via eNPP1 and its degradation via ALP) in physiological conditions. METHODS AND FINDINGS 45 patients in hemodialysis were studied. Physiological ALP activity represents only 4-6% of clinical activity. ALP activity increased post-hemodialysis by 2% under ideal conditions (87.4 ± 3.3 IU/L vs. 89.3 ± 3.6 IU/L) and 48% under physiological conditions (3.5 ± 0.2 IU/L vs. 5.2 ± 0.2 IU/L). Pyrophosphate synthesis by ATP hydrolysis remained unaltered post-hemodialysis. Post-hemodialysis plasma pH (7.45 ± 0.02) significantly increased compared with the pre-dialysis pH (7.26 ± 0.02). The slight variation in pH (~0.2 units) induced a significant increase in ALP activity (9%). Addition of phosphate in post-hemodialysis plasma significantly decreased ALP activity, although this effect was not observed with the addition of urea. Reduction in phosphate levels and increment in pH were significantly associated with an increase in physiological ALP activity post-hemodialysis. A decrease in plasma pyrophosphate levels (3.3 ± 0.3 μmol/L vs. 1.9 ± 0.1 μmol/L) and pyrophosphate/ATP ratio (1.9 ± 0.2 vs. 1.4 ± 0.1) post-hemodialysis was also observed. CONCLUSION Extraction of uremic toxins, primarily phosphate and hydrogen ions, dramatically increases the ALP activity under physiological conditions. This hitherto unknown consequence of hemodialysis suggests a reinterpretation of the clinical value of this parameter.
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Affiliation(s)
- Ricardo Villa-Bellosta
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (FIIS-FJD). Madrid, Spain
- Spanish Biomedical Research Network in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| | - Emilio González-Parra
- Renal Division, “Fundación Jiménez Díaz” University Hospital, Madrid Autonomous University, Madrid, Spain
| | - Jesús Egido
- Spanish Biomedical Research Network in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
- Renal Division, “Fundación Jiménez Díaz” University Hospital, Madrid Autonomous University, Madrid, Spain
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Abstract
Chloride (Cl)-depletion alkalosis (CDA) develops due to the loss of Cl-rich body fluid, i.e., vomiting or diuretics use, and is typically treated with a chloride-rich solution such as normal saline (NS). Although NS is one of the most utilized Cl-rich solutions, high cation-gap amino acid (HCG-AA) predominantly comprises Cl and less sodium, making HCG-AA more efficient in correcting CDA. We herein report a case of CDA with chronic hyponatremia after frequent vomiting, which was successfully treated with HCG-AA without overcorrecting hyponatremia or causing hypervolemia. HCG-AA may be more beneficial than NS for treating hyponatremic or hypervolemic metabolic alkalosis.
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Affiliation(s)
- Akihiro Ryuge
- Department of Nephrology and Hypertension, St. Marianna University School of Medicine, Japan
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Affiliation(s)
- Heather M Klingeman
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Ann E Kearns
- Advisor to resident and Consultant in Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.
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Fontana V, Santinelli S, Internullo M, Marinelli P, Sardo L, Alessandrini G, Borgognoni L, Ferrazza AM, Bonini M, Palange P. Effect of acetazolamide on post-NIV metabolic alkalosis in acute exacerbated COPD patients. Eur Rev Med Pharmacol Sci 2016; 20:37-43. [PMID: 26813451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Non-invasive ventilation (NIV) is an effective treatment in patients with acute exacerbation of COPD (AECOPD). However, it may induce post-hypercapnic metabolic alkalosis (MA). This study aims to evaluate the effect of acetazolamide (ACET) in AECOPD patients treated with NIV. PATIENTS AND METHODS Eleven AECOPD patients, with hypercapnic respiratory failure and MA following NIV, were treated with ACET 500 mg for two consecutive days and compared to a matched control group. Patients and controls were non invasively ventilated in a bilevel positive airway pressure (BiPAP) mode to a standard maximal pressure target of 15-20 cmH2O. RESULTS ACET intra-group analysis showed a significant improvement for PaCO2 (63.9 ± 9.8 vs. 54.9 ± 8.3 mmHg), HCO3- (43.5 ± 5.9 vs. 36.1 ± 5.4 mmol/L) and both arterial pH (7.46 ± 0.06 vs. 7.41 ± 0.06) and urinary pH (6.94 ± 0.77 vs 5.80 ± 0.82), already at day 1. No significant changes in endpoints considered were observed in the control group at any time-point. Inter-group analysis showed significant differences between changes in PaCO2 and HCO3- (delta), both at day 1 and 2. Furthermore, the length of NIV treatment was significantly reduced in the ACET group compared to controls (6 ± 8 vs. 19 ± 19 days). No adverse events were recorded in the ACET and control groups. CONCLUSIONS ACET appears to be effective and safe in AECOPD patients with post-NIV MA.
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Affiliation(s)
- V Fontana
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy.
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Hauguel M, Ait-Oufella H, Guidet B, Maury E, Bigé N. Hypokalemia and metabolic alkalosis: do not forget the patient's hands. Minerva Anestesiol 2014; 80:504-505. [PMID: 24257148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- M Hauguel
- Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique ‑ Hôpitaux de Paris, Paris, France -
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Affiliation(s)
- Nicholas Marston
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Devin Kehl
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Jonathan Copp
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Noureddin Nourbakhsh
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - Dena E Rifkin
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA; Veterans Affairs San Diego Healthcare System, San Diego, CA.
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García Martínez T, Montañés Pauls B, Reig Valero R, Roch Ventura MA, Ibáñez Benages E. [Hydrochloric acid for treatment of severe metabolic alkalosis]. Farm Hosp 2013; 37:337-8. [PMID: 24010696 DOI: 10.7399/fh.2013.37.4.684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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36
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Kościelska M, Mieczkowski M. [Alkalosis]. Wiad Lek 2013; 66:329-333. [PMID: 24490489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
An elevation of arterial blood pH called alkalosis remains an underestimated condition in hospitalized patients. Serious alkalosis can be associated with high risk of death. The disorder can be caused by increased concentration of bicarbonate (metabolic alkalosis) or decreased concentration of carbon dioxide (respiratory alkalosis). In most cases of metabolic alkalosis it is generated by vomiting or diuretic use, whereas respiratory alkalosis is provoked by hyperventilation associated with respiratory or neurological disorder. Maintenance of metabolic alkalosis is possible only in patients with impaired renal base excretion which is most often produced by hypochloremia. In both respiratory and metabolic alkaloses treatment depends on the underlying factor. In hyperventilation syndrome is based on behavioral therapy. In most cases of metabolic alkalosis the administration of sodium and potassium chloride forms a substantial part of therapy.
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Affiliation(s)
- Malgorzata Kościelska
- Katedra i Klinika Nefrologii, Dializoterapii i Chorób Wewnetrznych, Warszawski Uniwersytet Medyczny.
| | - Mariusz Mieczkowski
- Katedra i Klinika Nefrologii, Dializoterapii i Chorób Wewnetrznych, Warszawski Uniwersytet Medyczny
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37
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Siregar P. Sixteen years experience in six cases of Conn syndrome in Jakarta. Acta Med Indones 2012; 44:150-153. [PMID: 22745147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Primary hyperaldosteronism or Conn syndrome is the syndrome formed from the triad of hypertension, hypokalemia, and metabolic alkalosis. Six patients of Conn syndrome, two females (21 and 50 years) and 4 males (30, 33, 46, dan 51 years), were reported. All of the cases came with the symptoms of weakness of the lower extremities in conjunction with hypertension. The plasma aldosterone level was high with the very low plasma renin activity in all of the cases. All of the patients in this case had metabolic alkalosis. Unilateral adrenal mass was found on CT-Scan or MRI imaging. Following adrenalectomy, three patients (one female and two males) still needed one type of anti hypertension drug. All of the patients did not require anti aldosterone anymore. The plasma aldosterone returned to normal value in three patients while in three other patients were not checked. The histopathology of the adrenal revealed the adenoma of the adrenal cortex in all of the six cases.
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Affiliation(s)
- Parlindungan Siregar
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia.
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Brito JP, Singh E, Basu A. Iatrogenic heart block during treatment of a patient with Cushing's syndrome: report of a case. Endocrine 2012; 41:344. [PMID: 22124942 DOI: 10.1007/s12020-011-9567-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sotirakopoulos N, Kalogiannidou I, Tersi M, Armentzioiou K, Sivridis D, Mavromatidis K. Acid-base and electrolyte disorders in patients with diabetes mellitus. Saudi J Kidney Dis Transpl 2012; 23:58-62. [PMID: 22237220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Diabetes mellitus is the most common metabolic disorder in the community. The diabetics may suffer from acid-base and electrolyte disorders due to complications of diabetes mellitus and the medication they receive. In this study, acid-base and electrolyte disorders were evaluated among outpatient diabetics in our hospital. The study consisted of patients with diabetes mellitus who visited the hospital as outpatients between the period January 1, 2004 to December 31, 2006. The patients' medical history, age and type of diabetes were noted, including whether they were taking diuretics and calcium channel blockers or not. Serum creatinine, proteins, sodium, potassium and chloride and blood gases were measured in all patients. Proteinuria was measured by 24-h urine collection. Two hundred and ten patients were divided in three groups based on the serum creatinine. Group A consisted of 114 patients that had serum creatinine < 1.2 mg/dL, group B consisted of 69 patients that had serum creatinine ranging from 1.3 to 3 mg/dL and group C consisted of 27 patients with serum creatinine > 3.1 mg/dL. Of the 210 patients, 176 had an acid-base disorder. The most common disorder noted in group A was metabolic alkalosis. In groups B and C, the common disorders were metabolic acidosis and alkalosis, and metabolic acidosis, respectively. The most common electrolyte disorders were hypernatremia (especially in groups A and B), hyponatremia (group C) and hyperkalemia (especially in groups B and C). It is concluded that: (a) in diabetic outpatients, acid-base and electrolyte disorders occurred often even if the renal function is normal, (b) the most common disorders are metabolic alkalosis and metabolic acidosis (the frequency increases with the deterioration of the renal function) and (c) the common electrolyte disorders are hypernatremia and hypokalemia.
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Metso S, Arola J, Raade M, Välimäki M. [Clinico-pathological conference report: sudden deterioration of general condition, hypokalemia and diabetes in an elderly man]. Duodecim 2012; 128:1487-1496. [PMID: 22937608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
An elderly man had been treated for prostate cancer with radiation and neoadjuvant hormonal therapy. One year after the cessation of radiation therapy, the PSA value was found to be elevated. A non-steroidal antiandrogen bicalutamide was initiated to the patient. Due to poor treatment response the drug was changed for the GnRH agonist leuprorelin acetate, which upon injection caused a sudden deterioration of the patient's general condition. He was delirious and in pain, and was diagnosed with leukocytosis, hypokalemia, hyperglycemia and metabolic alkalosis. The patient was referred to the endocrinological clinic for evaluation of the metabolic-endocrinological problems. He succumbed to disseminated prostate cancer.
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Alshayeb H, Patel V, Naseer A, Mangold TA, Wall BM. Multiple myeloma with hypercalcemia and chloride resistant metabolic alkalosis. Tenn Med 2011; 104:47-49. [PMID: 22073517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This report describes a novel presentation of chloride resistant metabolic alkalosis in a patient with hypercalcemia related to Multiple Myeloma (MM). A 51-year-old male with newly diagnosed MM presented with widespread skeletal involvement, calcium (Ca(+2)) of 18 mg/dL, phosphorous (PO4) of 6 mg/dL, serum bicarbonate (HCO3) of 37 mEq/L, and serum creatinine (Cr) of 2.6 mg/dL Other causes of metabolic alkalosis such as vomiting, diuretics, alkali ingestion, mineralocorticoid excess and hypokalemia were excluded. Hypercalcemia and metabolic alkalosis were only partially corrected after rehydration, calcitonin and steroids. Subsequent treatment with zoledronic acid resulted in resolution of hypercalcemia and correction of metabolic alkalosis.The chloride resistant component of metabolic alkalosis was most likely related to extensive release of Ca(+2), carbonate and phosphate from bone by activated osteoclasts with inhibited osteoblastic activity. The additional reduction in glomerular filtration rate due to MM, contributed to a triad mimicking Calcium-Alkali syndrome.
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Affiliation(s)
- Hala Alshayeb
- University of Tennessee Health Science Center, Memphis, TN, USA
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Abstract
INTRODUCTION Pendred syndrome, a combination of sensorineural deafness, impaired organification of iodide in the thyroid and goitre, results from biallelic defects in pendrin (encoded by SLC26A4), which transports chloride and iodide in the inner ear and thyroid respectively. Recently, pendrin has also been identified in the kidneys, where it is found in the apical plasma membrane of non-α-type intercalated cells of the cortical collecting duct. Here, it functions as a chloride-bicarbonate exchanger, capable of secreting bicarbonate into the urine. Despite this function, patients with Pendred syndrome have not been reported to develop any significant acid-base disturbances, except a single previous reported case of metabolic alkalosis in the context of Pendred syndrome in a child started on a diuretic. CASE REPORT We describe a 46-year-old female with sensorineural deafness and hypothyroidism, who presented with severe hypokalaemic metabolic alkalosis during inter-current illnesses on two occasions, and who was found to be homozygous for a loss-of-function mutation (V138F) in SLC26A4. Her acid-base status and electrolytes were unremarkable when she was well. CONCLUSION This case illustrates that, although pendrin is not usually required to maintain acid-base homeostasis under ambient condition, loss of renal bicarbonate excretion by pendrin during a metabolic alkalotic challenge may contribute to life-threatening acid-base disturbances in patients with Pendred syndrome.
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Affiliation(s)
| | | | | | | | - Fiona Karet
- Department of Medical Genetics and Division of Renal MedicineUniversity of CambridgeCambridgeUK
- (Correspondence should be addressed to F Karet at Cambridge Institute for Medical Research, Addenbrooke's Hospital Box 139, Hills Road, Cambridge CB2 0XY, UK; )
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Marah MA. Pseudo-Bartter as an initial presentation of cystic fibrosis. A case report and review of the literature. East Mediterr Health J 2010; 16:699-701. [PMID: 20799601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- M A Marah
- Paediatric Department, Al Ain Hospital, Al Ain, United Arab Emirates.
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Sundar U, Lakkas Y, Asole D, Vaidya M. Gitelman's syndrome presenting as recurrent paralytic ileus due to chronic renal tubular K+ wasting. J Assoc Physicians India 2010; 58:322-324. [PMID: 21117354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Gitelman' syndrome, although a relatively frequent cause of chronic hypokalemia in adults, is rarely diagnosed correctly. It is frequently confused with overt diuretic abuse or Bartter's syndrome. We describe a 60 year man with 2 year history of recurrent paralytic ileus attributed to recurrent hypokalemia. Investigations in this patient revealed hypokalemia, metabolic alkalosis, hypocalciurea, and hypomagnesemia a tetrad diagnostic of Gitelman's syndrome. The peculiar clinical features of this condition and its management are discussed.
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Affiliation(s)
- Uma Sundar
- Internal Medicine, Service, Lokmanya Tilak Municipal General Hospital and Medical College, Mumbai, India
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Affiliation(s)
- Simru Tugrul
- Departments of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Lumpaopong A, Thirakhupt P, Srisuwan K, Chulamokha Y. Rare F311L CFTR gene mutation in a child presented with recurrent electrolyte abnormalities and metabolic alkalosis: case report. J Med Assoc Thai 2009; 92:694-698. [PMID: 19459534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Delta F508 mutation is recognized as the most common genotype of cystic fibrosis (CF) however, there are small numbers of CF patients having Delta F508/F311L. In the present study, the authors report a 2-year-old Thai boy, originating from North India, presenting with recurrent episodes of febrile illness, hyponatremia, hypokalemia, and metabolic alkalosis since 4 months of age. He was transferred to our hospital for further investigation. Blood chemistry revealed the following serum electrolytes, sodium 122, potassium 3.69, chloride 79.7, and bicarbonate 33.8 mEq/L, and the following urine electrolytes, sodium < 10, potassium 45.7 and chloride < 10 mEq/L. After intravenous fluid administration, hyponatremia and metabolic alkalosis improved DNA sequencing analysis of his blood demonstrates compound mutation for Delta F508 and F311L in CFTR gene. In conclusion, the authors report a rare case of CF with Delta F508/F311L genotype presented with recurrent hyponatremia and metabolic alkalosis. Awareness of electrolyte abnormalities during febrile illness, proper genetic counseling, and long-term follow up are necessary in this patient.
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Affiliation(s)
- Adisorn Lumpaopong
- Pediatric Nephrology Division, Phramongkutklao Hospital, Bangkok, Thailand.
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Lejeune B, Lorenz I. Ultrasonographic findings in 2 cows with duodenal obstruction. Can Vet J 2008; 49:386-388. [PMID: 18481548 PMCID: PMC2275343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Two cases where clinical findings suggestive of proximal ileus resulting in hypokalemic and hypochloremic alkalosis are presented. Ultrasonographs showed distension of the sigmoid flexure along the ventral border of the liver and between the serosal lamellae of the greater omentum in the flank, allowing exact preoperative obstruction localization.
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Affiliation(s)
- Beatrice Lejeune
- Clinic for Ruminants, University of Munich, Sonnenstrasse 16, D-85764 Oberschleissheim, Germany.
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Affiliation(s)
- Christoph Schwarz
- 3. Interne Abteilung mit Schwerpunkt Nephrologie, Krankenhaus der Elisabethinen Linz, Linz, Osterreich.
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Edwards SL. Pathophysiology of acid base balance: the theory practice relationship. Intensive Crit Care Nurs 2007; 24:28-38; quiz 38-40. [PMID: 17689248 DOI: 10.1016/j.iccn.2007.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 05/03/2007] [Accepted: 05/13/2007] [Indexed: 11/28/2022]
Abstract
There are many disorders/diseases that lead to changes in acid base balance. These conditions are not rare or uncommon in clinical practice, but everyday occurrences on the ward or in critical care. Conditions such as asthma, chronic obstructive pulmonary disease (bronchitis or emphasaemia), diabetic ketoacidosis, renal disease or failure, any type of shock (sepsis, anaphylaxis, neurogenic, cardiogenic, hypovolaemia), stress or anxiety which can lead to hyperventilation, and some drugs (sedatives, opioids) leading to reduced ventilation. In addition, some symptoms of disease can cause vomiting and diarrhoea, which effects acid base balance. It is imperative that critical care nurses are aware of changes that occur in relation to altered physiology, leading to an understanding of the changes in patients' condition that are observed, and why the administration of some immediate therapies such as oxygen is imperative.
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Affiliation(s)
- Sharon L Edwards
- Buckinghamshire Chilterns University College, Chalfont Campus, Newland Park, Gorelands Lane, Chalfont St. Giles, Buckinghamshire, United Kingdom.
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