CLINICAL PROBLEM-SOLVING

Metabolic acidosis

Ana Bernardo
MD, Nephrologist Assistant
Mdulo Urogenital 2 Ano do Curso de Medicina

Faculdade de Cincias da Sade - UBI

10 April 2014

FISIOLOGIA RENAL A REABSORO DE BICARBONATO

Cerca de 90% do bicarbonato reabsorvido no TCP

Fig.2 e 3. Guyton AC. Textbook of Medical Physiology. Regulation of acid-base balance. 11th ed. 2006

FISIOLOGIA RENAL A SECREO DE IES DE HIDROGNIO

A excreo diria de hidrognio deve ser equivalente
ingesta diria de cidos e corresponde aproximadamente a
1 mEq/Kg.
O pH urinrio mnimo de 4.5 pelo que apenas uma
pequena quantidade de ies H+ pode ser excretada na
urina na sua forma livre.
Amnia e fosfato so os principais tampes no TC.
A secreo de NaHPO4 e de NH4+ correspondem
gerao de novo bicarbonato.

Fig. 4. Comprehensive Clinical Nephrology, 4th ed, 2010. Fig. 5. www.uptodate.com

DA FISIOLOGIA PATOLOGIA
EM QUE CONTEXTO PODE SURGIR UMA ACIDOSE METABLICA?
Mechanism of acidosis
Increased acid production

Increased AG

Normal AG

Lactic acidosis
Ketoacidosis

Diabetes mellitus
Starvation
Alcohol-associated
Ingestions
Methanol
Ethylene glycol
Aspirin
Toluene (if early or if kidney function is impaired)

Toluene ingestion (if late and if renal function is preserved - due to excretion of sodium and potassium
hippurate in the urine)

Diethylene glycol
Propylene glycol

D-lactic acidosis
Pyroglutamic acid (5-oxoproline)

Loss of bicarbonate or bicarbonate precursors

Diarrhea or other intestinal losses (eg, tube drainage)

Renal ou gastrointestinal

Type 2 (proximal) renal tubular acidosis (RTA)

Posttreatment of ketoacidosis
Carbonic anhydrase inhibitors
Ureteral diversion (eg, ileal loop)

Decreased renal acid excretion

Chronic kidney disease

Chronic kidney disease and tubular dysfunction (but relatively preserved glomerular filtration rate)
Type 1 (distal) RTA

Type 4 RTA (hypoaldosteronism)

Renal

DA FISIOLOGIA PATOLOGIA
O HIATO ANINICO PODE AJUDAR A DIAGNOSTICAR A CAUSA DE UMA ACIDOSE METABLICA

Anies no medidos + anies medidos = Caties no medidos + caties medidos

Anies no medidos + (HCO3-) + (Cl-) = Caties no medidos + Na+
Anies no medidos - Caties no medidos = = Na+ - [(HCO3-) + (Cl-)]

Anion Gap

Anion Gap = valor normal entre 3 13 mEq/L

Se estiver aumentado porque existem no sangue valores elevados de anies no medidos
habitualmente cidos no volteis como o lactato ou os cetocidos.
Nas restantes situaes de acidose o hiato aninico est mantido. Estas devem-se ou perda de bicarbonato
(intestino ou rim) ou incapacidade do rim em secretar ies de H+ ou de produzir amnio.

ACIDOSES TUBULARES RENAIS PRINCIPAIS CARACTERSTICAS

Hyperkalemic RTA Type 4 RTA
Type 1 RTA

Type 2 RTA

(hypoaldosteronism) and distal tubule

voltage defects

Primary defect

Impaired distal acidification

Reduced proximal bicarbonate reabsorption

Decreased aldosterone secretion or aldosterone

resistance. Reduced sodium reabsorption in the
distal tubule (voltage defect).

Plasma bicarbonate

Variable,<20

Usually 12 to 20 meq/L

Variable (greater than 17 mEq/L in

hypoaldosteronism)

Urine pH

Greater than 5.3

Less than 5.3 when the serum HCO3 is reduced to

usually less than 5.3 with hypoaldosteronism

levels that can be largely reabsorbed despite defective

proximal tubule reabsorptive mechanisms.

Plasma potassium

Usually reduced but hyperkalemic forms exist;

Reduced, made worse by bicarbonaturia induced by alkali

hypokalemia largely corrects with alkali therapy

therapy

Increased

REVISO SOBRE ACIDOSE TUBULAR RENAL DISTAL TIPO 1

Fig.6 Clula intercalada alfa (www.uptodate.com)

Fig. 7 Clula Principal (www.uptodate.com)

Para manter o gradiente elctrico ao nvel do TC, e uma vez que h um defeito de secreo de ies H+, existe
compensatoriamente um aumento da actividade das clulas principais que reabsorvem Na+ em troca do catio
K+. Por este motivo os doente com ATR distal tipo 1 tm habitualmente uma hipocalimia.

DA FISIOLOGIA PATOLOGIA
CAUSAS DE ACIDOSE TUBULAR RENAL DISTAL
Primary
Idiopathic (sporadic)
Familial
Autosomal dominant (mainly due to mutations causing defects in the kidney anion exchanger - kAE1 in distal tubule intercalated cells)
Autosomal recessive (mainly due to mutations causing defects in V-ATPase in distal tubule intercalated cells)

Secondary
Autoimmune disorders
Sjgren's syndrome
Autoimmune hepatitis/primary biliary cirrhosis
Systemic lupus erythematosus (may be hyperkalemic)
Rheumatoid arthritis

Drugs
Ifosfamide
Amphotericin B
Lithium carbonate

Toluene inhalation

Hypercalciuric conditions
Hyperparathyroidism

Vitamin D intoxication
Sarcoidosis
Idiopathic hypercalciuria