Renal Tubular Acidosis

By: Nidisaa.R
1802001078
 What’s Inside?
 Metabolic Acidosis
 Anion gap
 Renal tubular acidosis
 Types
 diagnosis
 Metabolic Acidosis
• Due to accumulation of any acid (except carbonic acid).
• Primary decrease in plasma HCO3- .

DISORDERS CAUSING METABOLIC ACIDOSIS:

ACID ADMINISTRATION

ACID GENERATION [LACTIC ACIDOSIS DURING SHOCK, CARDIAC

ARREST]

IMPAIRED ACID EXCRETION

GI / KIDNEY DISORDERS – BICARBONATE LOSS

 Anion Gap

• Identifies if acidosis is due to retention of H+Cl- .

• Normal cations in plasma = Na+, k+, Ca2+, Mg2+.
• Normal anions in plasma = Cl-, HCO3-, albumin, phosphate, sulphate.
• The sums of positive and negative charges are equal.
• Measurement of plasma [Na+], [K+], [Cl-], [HCO3-] is easily available.
• More anions than cations, so, normal anion gap of 12-16 mmol/L.
 Metabolic acidosis with Normal Anion gap:
• Anion gap can be normal even in the presence of acidosis.
• This suggests either H+Cl- is being retained or Na+HCO3- is being lost.
 Renal Tubular Acidosis:
• Systemic acidosis caused by impairment of ability of renal tubules to maintain acid-
base balance.
• Rare disorder.
 Type 4 , RTA
• Deficiency or unresponsiveness to Aldosterone.
• Type 4 RTA AKA Hyporeninaemic Hypoaldosteronism.
• MC form of RTA.

CARDINAL FEATURES:

Hyperkalaemia

Acidosis in patients with mild CKD due to Tubulointerstitial d/s, Diabetes.

Features of type 4 RTA:

Hyperkalaemia

Low plasma bicarbonate and hyperchloraemia

Normal ACTH Stimulation test

Low basal 24h urinary Aldosterone

Subnormal response of plasma Renin and plasma Aldosterone to stimulation

Correction of hyperkalaemia by Fludrocortisone 0.1 mg daily

 Type 3, RTA
• Vanishingly very rare condition.
• Combination of type 1 and 2.
• Inherited RTA type 3 is caused by mutations resulting in Carbonic Anhydrase type 2
deficiency, characterised by osteopetrosis, RTA of mixed type, cerebral calcification,
mental retardation.
 Type 2, RTA [Proximal]
• Very rare.
• Caused by failure of Sodium Bicarbonate reabsorption in proximal tubule.

Cardinal Features:

Acidosis

Hypokalaemia

Inability to to lower urine Ph below 5.5 despite systemic acidosis

Bicarbonate in urine despite subnormal plasma bicarbonate

Type 1, RTA [Distal]
• Failure of H+ excretion in distal tubule.
 Diagnosis of Renal Tubular Acidosis
• Plasma HCO3- <21 mmol/L, Urine pH > 5.3 = RTA
• Distal RTA: defect in dietary acid excretion. Urine pH> 5.5.
• Proximal RTA: defect in bicarbonate reabsorption. Urine pH variable.

Bicarbonate infusion test Acid load test

Use bicarbonate infusion to raise serum bicarbonate to 18-20
mmol/L.
If urine Ph rises to > 7.5 & fractional excretion of bicarbonate
rises to >15%, then defect is bicarbonate reabsorption &
diagnosis is prox RTA.
If little change in urine ph and fractional bicarbonate is low,
distal RTA.
Give 100 mg/kg ammonium chloride by mouth.
Check urine ph hourly and plasma HCO3- at 3h.
Plasma HCO3- should drop below 21mmol/L unless the
patient vomits
If urine ph remains >5.3 despite a plasma HCO3- of
21mmol/L, diagnosis is confirmed.