Acid base disorder

Tim dosen patologi

The concept of acid base balance

Acid-base balance refers to the mechanisms
the body uses to keep its fluids close to neutral
pH (that is, neither basic nor acidic) so that the
body can function normally.
Arterial blood pH is normally closely
regulated to between 7.35 and 7.45.

Any
ionic
or
molecular
substance that can act as a
proton donor.
Strong acidHCl, H2SO4, H3PO4.
Weak acidH2CO3, CH3COOH.

acids??

Any ionic or molecular

substance that can act as a
proton acceptor.
Strong alkaliNaOH, KOH.
Weak alkali NaHCO3, NH3,
CH3COONa.

bases??

Origin of acids

Much more

Intracellular metabolism
Volatile
acids

Fixed
acids

CO2+H2O=H2CO3
Lactic acid
Ketone bodies
Sulfuric acid
Phosphoric acid

Origin of bases

300~400L CO2 (15mol H+)

50~100 mmol H+

less NH3 , sodium citrate, sodium lactate

ACID BASE BALANCE AND

REGULATION

pH
pH of ECF is between 7.35 and 7.45.
Deviations, outside this range affect
membrane function, alter protein function,
etc.
You cannot survive with a pH <6.8 or >7.7
Acidosis- below 7.35
Alkalosis- above 7.45

CNS function deteriorates, coma, cardiac

irregularities, heart failure, peripheral
vasodilation, drop in BP.

 Given that normal body pH is slightly alkaline and that

normal metabolism produces acidic waste products
such as carbonic acid (carbon dioxide reacted with
water) and lactic acid, body pH is constantly
threatened with shifts toward acidity.
In normal individuals, pH is controlled by two major
and related processes pH regulation and pH
compensation.

Regulation is a function of the buffer systems of the

body in combination with the respiratory and renal
systems, whereas compensation requires further
intervention of the respiratory and/or renal systems to
restore normalcy.

buffering
H+ + A

HA

[ H+ ] [ A ]
Ka =

H+ ]

[ HA ]

= Ka

[ HA ]

[A ]
pH = pKa + lg

[ A ]
[ HA ]

ACID-BASE
BUFFERING

by the body fluids that immediately combine with acids

or base to prevent excessive changes in pH

which regulates the removal of volatile CO2 as a gas in

the expired air from the plasma and therefore also
regulates bicarbonate (HCO3-) from the body fluids via
RESPIRATORY
the pulmonary circulation.

KIDNEYS

which can excrete either acid or alkaline urine, thereby

adjusting the pH of the blood.

H load
ECF
Buffers

Lung
RBC

Hb
buffers

ICF

Respiratoryc
ontrol

H K
exchange

H2CO3 CO2

Buffers

others

Renal
H+ excretion
bicarbonate
reabsorption

Expiration

minutes

hours

Release
bone salt

Ca2 H2PO4

Acid
excretion

Immediately

Bone

days

In chronic
metabolic
acidosis

Very slow

Buffers system extracellular

Renal control of acid-base balance

The kidneys control acid-base balance by excreting
either an acidic or basic urine.
The kidney filters large volumes of HCO3- and the extent to
which they are either excreted or reabsorbed determines
the removal of base from the blood.
The kidney secretes large numbers of H+ into the tubule
lumen, thus removing H+ from the blood.

The gain of the adjustment of pH by the kidney and

the acid base balance it regulates is nearly infinite,
which means that while it works relatively slowly, it can
COMPLETELY correct for abnormalities in pH.

 The kidneys regulate extracellular fluid pH by secreting H +,

reabsorbing HCO3-, and producing new HCO3 During alkalosis, excess HCO3- is not bound by H+, and is
excreted, effectively increasing H + in the circulation and
reversing the alkalosis.
In acidosis, the kidneys reabsorb all the HCO 3- and produce
additional HCO3-, which is all added back to the circulation
to reverse the acidosis.

H+ is secreted and HCO3- reabsorbed in all segments of the

kidney except for the thin limbs of the loop of Henle.
(however, HCO3- is not readily permeable through the
luminal membrane).

Primary
changing

CO2

CO2 + H2O
CA

HCO3

RBC

H2CO3
CA

plasma

C l

HCO3

C l

H+

Hb buffering

Cl transfer
CA carbonic anhydrase

The compensation effect of RBC

uBuffers

solution.

only

provide

temporary

uLung:

responds rapidly to altered

plasma H+ concentrations, and keep
blood levels under control until the
kidneys eliminate the imbalance.

uKidney:

are the ultimate H+ ions balance.

Slow acting mechanisms can eliminate
any imbalance in H+ levels.

ACID BASE DISTURBANCE

Definition of acid-base disorders

An acid base disorder is a change in the normal

value of extracellular pH
When is it happen??
renal or respiratory function is abnormal
an acid or base load overwhelms excretory capacity

Simple acid base disorders

Clinical disturbances of acid base metabolism
classically are defined in terms of the
HCO3 /CO2 buffer system.
Acidosis : process that increases [H+]
increasing PCO2 or by reducing [HCO3-]

Alkalosis : process that reduces [H+]

reducing PCO2 or by increasing [HCO3-]

 Since PCO2 is regulated by respiration,

abnormalities that primarily alter the PCO2
are referred to as respiratory acidosis (high
PCO2) and respiratory alkalosis (low PCO2).
In contrast, [HCO3] is regulated primarily by
renal processes. Abnormalities that primarily
alter the [HCO3] are referred to as metabolic
acidosis (low [HCO3]) and metabolic
alkalosis (high [HCO3]).

PaCO2
(Partial Pressure of Carbon Dioxide)
The amount of carbon dioxide dissolved in arterial blood.
Normal: 4.39 6.25kPa35 45 mmHg
Average: 5.32 kPa40 mmHg
Respiratory acidosis: > 45 mmHg

Respiratory alkalosis: <35 mmHg

The PaCO2 reflects the exchange of this gas through the lungs
to the outside, so it is called respiratory parameter.

HCO3

Normal: 21 26 mmHg

Average: 24 mmHg

Metabolic acidosis: < 21 mmHg

Metabolic alkalosis: > 26 mmHg

pH
pH is a measurement of the acidity of the blood, reflecting
the number of hydrogen ions present.
pH = - log [H+]
pH7.45alkalosis
pH7.35acidosis
pH 7.35 - 7.45
Acid-base balance.
Acidosis or alkalosis with complete compensation.
A mixed acidosis and alkalosis, both events have opposite
effects on pH, may also have a normal pH.

assessment of the arterial blood gas

profile >> penilaian pH
appraisal of the pCO2 and [HCO3-] to
identify the primary derangement
and compensatory response
assessing the adequacy of the
compensatory response by applying
the rules of compensation
examine the serum electrolytes and
anion gap (AG) and to decide
whether additional testing is required

Step
analisis
kasus

Compensation
The body response to acid-base imbalance is called
compensation
Complete if brought back within normal limits
Partial compensation if range is still outside norms.
If underlying problem is metabolic, hyperventilation or
hypoventilation can help respiratory compensation.
If problem is respiratory, renal mechanisms can bring
about metabolic compensation.

Asidosis

pCO2
HCO3??
N : belum terjadi kompensasi
: kompensasi renal (parsial)
: mixed (respiratory &
metabolic disorder)

HCO3

PCO2??
N : belum terjadi kompensasi
: kompensasi paru (parsial)
: mixed disorder

Alkalosis

pCO2
HCO3??
N : belum terjadi kompensasi
: mixed (respiratory &
metabolic disorder)
: kompensasi renal (parsial)

HCO3

PCO2??
N : belum terjadi kompensasi
: mixed disorder
: kompensasi paru (parsial)

Lactic acidosis

Source ketoacidosis

Acids

Fixed acids

Salicylic acidosis

AG : anion gap

generate
intake

Exclusion renal failure

Source

Bases

Loss

impossible
From GIdiarrhea
From kidneyproximal/distal tubular acidosis

Consume ammonium chloride have been administered

Increased AG

Primary

[HCO3]

Normal AG

Metabolic
acidosis

Metabolic Acidosis occurs when the kidneys fail to excrete

acids formed in the body, or there is excess ingestion of acids,
or the loss of bases from the body
Renal Tubular Acidosis: due to a defect in H+ secretion or
HCO3- reabsroption.
Diarrhea: Excess HCO3- loss into the feces without time to
reabsorb (most common cause).
Diabetes mellitus: In the absence of normal glucose
metabolism the cells metabolize fats and form acetoacetic
acid, reducing pH, and inducing renal acid wasting.
Chronic renal failure: decreased renal function results in acid
build-up in the circulation and reduced HCO3- reabsorption.
Acid ingestion: toxins such as aspirin or methyl alcohol result
in excess acid formation.

Metabolic
alkalosis

Primary [HCO3]

Source impossible
Fixed acids
Loss

Bases

From GI vomiting, gastric suction

K+ or Cl deficiency
Hyperaldosteronism
From kidney Cushings syndrome
Diuretic therapy

Source Alkali administrationNaHCO3

sodium lactate .
Exclusion impossible

Metabolic Alkalosis: occurs when there is excess retention

of HCO3- or excess loss of H+ from the body
Diuretic therapy: many diuretics increase tubular flow,
resulting in increased Na load, increased Na reabsorption
and therefore increased HCO3- reabsorption.
Excess Aldosterone: which promotes excess Na
reabsorption and stimulates H+ secretion.
Vomiting: loss of the acidic contents of the stomach
creates a depletion of H+ which is compensated for by
removing more H+ from the circulation.
Ingestion of alkaline drugs such as NaHCO3- used for
upset stomachs and ulcers.

Loss of H+

Severe
vomiting

Loss of Cl
Loss of K +
Loss body fluid

 Respiratory Acidosis is the inability of the lungs

to eliminate CO2 efficiently; so the equilibrium
shifts toward increased H+ and HCO3-; therefore,
pH decreases.
Respiratory Acidosis: CO2 + H2O H+ + HCO3-

Respiratory Alkalosis is excessive loss of CO2

through ventilation driving the equilibrium to the
left away from H+ therefore, pH increases.
Respiratory Alkalosis: CO2 + H2O H+ + HCO3-

Respiratory
acidosis

Primary [H2CO3 or CO2 ]

Exhalation failure of ventilation

Volatile acid
inhalation

Respiratory
alkalosis
Volatile acid

inhale CO2 at high concentration

Primary [H2CO3 or CO2 ]

hypoxemia, anxiety, hysteria,
Exhalation Salicylate intoxication
CNS diseases

The metabolic or renal regulation of the balance of H+ or

HCO3- excreted will determine if there is a net loss of H+ or
HCO3-, and will determine the pH of the urine.

CO2 + H2O H+ + HCO3-

Filtered

Nephron
Secreted

Reabsorbed

Note: the renal regulation of the

equilibrium between H+ and CO2 takes
place on the right side of the
equation
Urine (excreted)

Overall, the kidneys must

excrete H+ and prevent
the loss of HCO3-.
Filtered HCO3- must react
with secreted H+ in order
to be reabsorbed as
H2CO3

Mixed acid base disorder

Acidosis + alkalosis in a patient
More than one acid base disturbance present
pH may be normal or abnormal.

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