ROLE OF THE KIDNEY

IN ACID-BASE REGULATION

Ketut Suwitra

Division of Nephrology
Department of Medicine Faculty of Medicine
Udayana University-Sanglah Hospital Denpasar
Body fluid pH is tightly controlled
because most of enzyme reaction are
sensitive to pH changes

Normal pH range is 7.38 7.42

Normal H+ concentration 0.38 0.42
Acid-base balance

pH = - log [H+]

[pH] 7.40 7.30 7.0 6.82

[H+] 0 40 50 100 150

(nM)

Alkalemia Acidemia

Acidemia and alkalemia are defined by plasma pH or

hydrogen ion concentrations.
Vishnu Moorthy., Pathophysiology of Kidney Disease and Hypertension 2009
Acid-base balance regulate by :
Buffer system in mild imbalanced and short time
Respiratory system / lung
Urinary system / kidney strong and most
important regulator
Lung, buffers, and kidney in acid-base balance

pH = 7.400.02
[H+] = 402 nM

buffer buffer

PCO2 = 40 2 HCO3- = 24 2

Equilibrium
Metabolic acidosis : HCO3-
Metabolic alkalosis : HCO3-
Respiratory acidosis : PCO2
Respiratory alkalosis : PCO2
Acidemia : pH, [H+]
Alkalemia : pH, [H+]

Vishnu Moorthy., Pathophysiology of Kidney Disease and Hypertension 2009

 Buffer systems in different body compartment

Buffer systems Blood ECF and CSF ICF

HCO3- / CO2
Haemoglobin
Plasma proteins
Phosphate
Organic phosphate
Proteins
Note: CSF, cerebrospinal fluid; ECF, extracellular fluid;
ICF, intracellular fluid

Thomas, Stanley, Datta., Real and Urinary System, 2007

When there is a disturbance either
in carbon dioxide (CO2) levels, which are primarily
regulation by the lungs, or in bicarbonate (HCO3) levels,
which are primarily regulation by the kidneys,
there is a compensatory change in other component

Davenport, 1973
 50 pCO2 9.3 kPa
pCO2 5.3 kPa
C C
40 pCO2 2.7 kPa
D D
HCO3- (mmol/L)

30
N
D
20 D

10 C C

7.0 7.2 7.4 7.6 7.8 pH

N = normal D = disease C= compensation

Respiratory acidosis metabolic acidosis
Respiratory alkalosis metabolic alkalosis

DAVENPORT DIAGRAM
Thomas R. Renal and Urinary Systems, 2007
 Kidney is the most important organ
in maintaining the acid-base balance

Bicarbonate
reabsorbtion

Kidney handling
of acid-base
Titratable acid
formation

Acid excretion

Formation of
urine ammonium
 filtered
filtered
HCO3- (mmol/min)

5.0

reabsorbed

2.5
Tm

0.0
0 20 40 60

Plasma HCO3- (mmol/L)

Renal regulation of plasma HCO3-

Thomas R. Renal and Urinary Systems, 2007
 Kidney regulation of acid-base
Vishnu Moorthy, Pathophysiology of Kidney Disease and Hypertension 2009
 Kidney bicarbonate
reabsorption
Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009
 Kidney titratable
acidity formation

Vishnu Moorthy, Pathophysiology of Kidney

Disease and Hypertension 2009
 Kidney ammonium
excretion
Vishnu Moorthy, Pathophysiology of Kidney
Disease and Hypertension 2009
CASE ILLUSTRATION
Metabolic Acidosis
Three major mechanism :
1. Bicarbonate loss
Kidney : Renal Tubular Acidosis
Gastrointestinal : Severe diarrhea

2. Excess metabolic production of H+

Diabetic Ketoacidosis
Excessive ingestion of H+ (methanol)

3. Renal Disease (AKI/CKD)

failure to excrete H+ and regenerate HCO3-
 Metabolic pH < 7.38
[H+] > 42 nM
acidosis

HCO3- < 22

Dysequilibrium

Primary condition:
Metabolic acidosis : HCO3-

Respiratory
compensation
pH = 7.40

Metabolic acidosis is
PCO2 HCO3- < 22
characteristic by a
decrease in serum
bicarbonate (HCO3-) levels New Equilibrium
Respiratory compensation:
Vishnu Moorthy, Pathophysiology of Kidney Hyperventilation : PCO2
Disease and Hypertension 2009
Summary
Maintenance body fluid pH (acid-base) is an important
condition for make an optimal enzymatic cell reaction

The kidney act together with buffer system and the

lungs to minimize any changes in plasma pH

Role of the kidney in acid-base regulation :

To reabsorb filtrated bicarbonate
To regenerate bicarbonate by excretion of
ammonium and titratable acids
TRI HITA KARANA

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