ACID BASE-BALANCE

Objectives :

Acids and bases - definition Relation between pH and pKa Physiological buffers and buffering capacity Control of acid-base balance Acidosis and alkalosis

Describe the role of the kidneys in maintaining a normal acid base balance. Describe the renal compensation for A-B imbalance Describe the tubular transport of hydrogen and bicarbonate ions Describe the regulation of water, sodium and potassium by the kidney and the disorders of their balance

Acids: An acid is a substance which dissociates in water releasing hydrogen ions (H+) or a proton donor. It has a pH range below 7.0.( HCL, acetic acid, lactic acid) HCL---------------- H+ + ClBase: A base is a substance which dissociates releasing hydroxyl ions (OH-) or proton acceptor. pH range above 7.0 (Sodium hydroxide, ammonium hydroxide) NaOH----------------- Na+ + OH-

NH3 + H+--------------NH4+

Strong acids: Dissociate completely, Complete ionization, Concentration of H+ is high Weak acids: Partial dissociation, Incomplete ionization, Concentration of H+ is less (50%)

For weak acids, The dissociation is freely reversible, at equilibrium the ratio between the dissociated and undissociated particle is constant. The dissociation constant is Ka

H+ concentration of hydrogen ions, A- - anions,

HA- concentration of undissociated molecules The pH at which the acid is half ionized is called pKa Strong acids have low pKa and week acids have higher pKa Acidity Acidity is measured by the hydrogen ion concentration in the solution and obtained by the equation H+ = Ka (acid) ------(base)

pH
The term pH was introduced by Sorenson (1909) and was defined as the negative log of hydrogen ion concentration i.e pH is inversely proportional to acidity

[H+]

can range from 1 M to 1 X 10-14 M

Low pH value correspond to high concentrations of H+ High pH values corresponds to low concentrations of H+.

Henderson-Hasselbalch Equation (HHB) The relationship between pH, pKa, concentration of acid and conjugate base (salt) is expressed by the HHB equation

Functional groups of weak acids have great physiological significance. Many biochemicals possess functional groups that are weak acids or bases. Carboxyl, amino, phosphate esters are present in all proteins and nucleic acids, coenzymes, intermediary metabolites. Dissociation behavior of weakly acidic and weakly basic functional groups is therefore fundamental for understanding the influence of intracellular pH on the structure and biochemical activity of these compounds. The separation and identification of the biochemical compounds in research and clinical medicine is facilitated by the knowledge of the dissociation behavior of their functional groups.

Buffers

Solutions that can resist changes in pH when acid or alkali is added. Two types:

Mixture of a weak acid and its salt with a strong base Mixture of a weak base and its salt with a strong acid Example:

CH3COOH/CH3COONa (acetic acid and sodium acetate)- acetate buffer

H2CO3/NaHCO3 (bicarbonate buffer) Na2HPo4/NaH2PO4 (Phosphate buffer)

Factors determining pH of a buffer: pKa- Lower the value of pKa, the lower is the pH of the solution Ratio of salt to acid concentrations- No change of pH as long as the ratio of salt
and acid remains the same.

On addition of acid, protons bind to conjugate base A- converting some of it to HA On addition of OH-, it is buffered by conversion of HA to A-

Buffer capacity

Defined as the ability of the buffer to resist changes in pH when an acid or base is added. Determined by the actual concentrations of salt and acid present as well as their ratio. Is the number of grams of strong acid or base needed for a change in pH of 1 unit of 1 liter of solution.

How do the buffers act? When hydrochloric acid is added to the acetate buffer, the salt reacts with the acid forming the weak acid acetic acid and its salt. Similarly when a base is added the acid reacts with its forming salt and water. Thus the changes in the pH can be minimized CH3COOH + NaOH --- CH3-COONa + H2O CH3-COONa + HCl --- CH3-COOH + NaCl The buffer capacity is determined by the absolute concentration of the salt and salt and acid. But the pH of the buffer is dependent on the salt and acid (HHB equation). When the ratio between salt and acid is 10:1, the pH will be unit higher than the PKa. When the ratio between salt and acids is 1:10, the pH will be lower than the pKa.

Effective range of buffer

A buffer is most effective when the concentration of salt and acid are equal or when pH = pKa. The effective range is 1 pH unit lower or higher than pKa.

Various buffer systems are: 1)-Bicarbonate buffer system- main extracellular buffer
: NaHCO3 / H2CO3 [H+] + [HCO3-] [H2CO3]

Normal H2CO3 is 1.2mmols/L and HCO3- is 24mmols/L and the ratio is 20:1 Bicarbonate represents the alkali reserve and should be high to neutralize the acid load.

2)Phosphate buffers : HPO4/H2PO4 = 5:1 3)Protein buffers albumin, Haemoglobin

Acid-base balance

Control of pH of body fluids

Normal pH- The pH of the plasma is 7.4, tightly regulated at pH7.4 (range of
7.35 to 7.45), pH
If

pH< 7.38, it is called acidosis. Acidosis leads to CNS depression and coma. Death occurs below 7.0 If pH> 7.42, condition is known as alkalosis. It is very dangerous if it is above 7.55. Alkalosis induces neuromuscular hyperexcitability and tetany.

Mechanisms of regulation of pH Three interrelated mechanisms to control pH caused by normal production of carbonic acid and non-volatile acids as well as pathological disturbances of acid-base balance. 1. Physiological buffer systems of the body 2. Respiratory system; Pulmonary excretion of CO2 3. Renal excretion of [H+] and [HCO3-]

Regulation of pH in the body

1. Physiological buffers

Bicarbonate

(HCO3-, ECF)

Solubility of CO2 obeys Henrys law in that its concentration in solution is proportional to its partial pressure. The ionization of carbonic acid is: H2CO3 H+ + HCO3In blood, the overall equilibrium for H2CO3 and CO2 is: CO2 + H2O H2CO3 H+ + HCO3[HCO3-] in plasma is 0.03M At pH7.4, [HCO3-]:[H2CO3] = 20:1 Bicarbonate resists pH change when blood is being acidified

Phosphate buffer (mainly ICF)

Ionization of phosphoric acid is as follows: H3PO4 H2PO4- + H+ (pKa = 2.0) H2PO4- HPO42- + H+ (pKa = 6.5) HPO42- PO43- + H+ (pKa = 12.7) [HPO42-]:[H2PO4-] = 4:1 in plasma This is a more efficient buffer than bicarbonate at physiological values.
Inorganic phosphate is the chief buffer in the urine.

Amino acids and proteins (ICF)

Buffering capacity of protein depends on the pka value of ionizable side chains. The most effective is histidine imidazole group There are 16 residues in albumin and 38 histidines in hemoglobin The role of the hemoglobin buffer is considered along with the respiratory regulation of pH.

Respiratory regulation
The second line of defense against change in pH, is the respiration.

The respiratory regulation of pH is achieved by changing the pCO2 (carbonic acid). The CO2 diffuses from the cells into the extra cellular and reaches the lungs through the blood. The rate of respiration (rate of elimination of CO2) is controlled by the chemo receptors in the respiratory centre which are sensitive to changes in the pH When there is a fall of pH of plasma (acidosis), the respiratory rate is stimulated resulting in hyperventilation.

This would eliminate more CO2, thus lowering the H2CO3.

However this cannot continue very long. The respiratory system responds to any change in pH immediately, but it cannot proceed to completion. By means of pulmonary compensation, the normal pH can be maintained near to normal, in spite of addition of 23 mEq of acids and 18 mEq of alkali.

Acid metabolites enter blood, pH HA H+ + A H+ + HCO3- H2CO3 CO2 + H2O Equilibrium far to the right. Dissociation of H2CO3 almost complete. pCO2 Rate of breathing and CO2 is eliminated until pH returns to normal.

Action of hemoglobin

The hemoglobin serves to transport the CO2 formed in the tissues, with the minimum change in pH. it serves to generate bicarbonate or alkali by the activity of the carbonic anhydrase system CO2 + H2O __________H2CO3

Renal regulation

Acid-base status cannot return to normal solely by physiological response of lung function. Minimum pH of urine = 4.5 0.03mM H+ ions Acids found in urine have wide range of pKa eg acetoacectic acid (pKa = 3.5), 3-hydroxybutyric acid (pKa = 4.7). Only way for excretion of H+ to be increased is by simultaneous excretion of a base. In normal urine, the only such base is HPO42Amount of H+ removed from solution by transfer of phosphate ions (pKa = 6.8) from pH 7.4 to 4.5 is 80% of phosphate excreted.

Acidosis
Causes of Acidosis: 1. Metabolic acidosis Formation of acids in the body eg lactic acid from intense exercise, oxidation of cys to sulphate, hydrolysis of nucleic acids to inorganic phosphate (non volatile acids). Reduction in plasma [HCO3-] due to passage of acids from tissues into plasma or insufficient bicarbonate production.
1.

2.

Respiratory acidosis Increase in pCO2 due to retention of CO2 through respiratory obstruction or respiratory failure.

Alkalosis
Bodys defense against alkalosis less effective than against acidosis. Buffer system:
H2CO3-HCO3-

buffer system has less capacity above pH7.4 Urine has little capacity to buffer OH- ions and no known mechanism for secreting OH- ions directly.

RENAL regulation of pH An important function of the kidney is to regulate the pH of the extracellular fluid. Kidney excretes urine (pH around 6) with a lower pH than that of ECF (7.4). This is called acidification of urine. The pH may vary between 4.5-9.8.

Kidney regulates pH by : Excretion of H+ ions Reabsorption of filtered HCO3 Excretion of titratable acid Excretion of ammonium (NH4+) ions

Excretion of H+ in the PCT

-process occurs in proximal convoluted tubules
Here, the H+ are secreted into the tubular lumen in exchange for Na+ which will be reabsorbed along with HCO3 into the blood. There is net excretion of H+ and generation of HCO3-

Reabsorption of HCO3Here, there is no net excretion of H+ or generation of new HCO3.This mech prevents loss of HCO3 through urine

Both the mechanisms work simultaneously

Excretion of titratable acid by Phosphate mechanism The term titratable acidity of urine refers to the number of milliliters of N/10 NaOH required to titrate 1 litre of urine to pH 7.4. This is a net measure of net acid excretion by the As the tubular fluid passes kidney

down the renal tubules more and more H+ ions are secreted into the luminal fluid so that pH steadily falls. Due to Na+-K+ exchange occurring at the renal tubular cell border, the basic phosphate ( Na2HPO4) is converted to acid phosphate(NaH2PO4) and helps excrete H+ with minimum change in pH. The main advantage of this system is that very large quantities of hydrogen ions are excreted with minimum change in PH. If this system is not available, the urinary pH will be acidic.

Excretion of H+- Ammonia mechanism

NH3 generated in renal tubular cells from glutamine by glutaminase passes into the lumen and traps H+ and excreted as NH4+ with minor changes in pH. In acidosis, glutaminase activity increases and more H+ excreted as NH4+

Disturbances in acid-base balance Increased concentration of hydrogen ions is called acidemia and a decrease is referred to as alkalemia. The clinical state, where acids are accumulated is the acidosis and a loss of acid or accumulation of base is the alkalosis
Acidosis (fall in pH)

a. Respiratory acidosis: Primary excess of carbonic acid

b. Metabolic acidosis: Primary deficiency of bicarbonate Alkalosis (rise in pH)

a. Respiratory alkalosis: Primary deficiency of carbonic acid

b. Metabolic alkalosis: Primary excess of bicarbonate

 1.

2.

Compensation mechanisms Adaptive response is always in the same direction as the primary disturbance . Primary decrease in arterial bicarbonate involves a reduction in arterial blood pCO2 Adaptive response involves a change in the counteracting variable; e.g a primary change in bicarbonate involve an alteration in Pco2. by hyper ventilation, and primary increase in arterial pCO2 involves an increase in arterial bicarbonate by an increase in bicarbonate re absorption by the kidney

Clinically, acid-base disturbance states may be divided into: (a) Uncompensated (b) Partially compensated (c) Fully compensated Primary changes may be either in the bicarbonate level (metabolic) or carbonic acid (respiratory) . The secondary compensatory change will affect the other parameter, try to restore the pH

In Metabolic acidosis :
[H+] pCO2 [HCO3] Acidosis develops [H] pCO2 [HCO3] Respiratory compensation occurs quickly

ventilation

In Metabolic alkalosis :
[H+] pCO2 [HCO3] Alkalosis develops [H] pCO2 [HCO3] Respiratory compensation occurs quickly

ventilation

Metabolic acidosis

Primary deficit in the bicarbonate May be due to accumulation of acid or depletion of bicarbonate When there is excess of acid production, bicarbonate is used for buffering Anion gap is altered
ANION GAP The sum of cations and anions in ECF is always equal, so as to maintain the electrical neutrality sodium and potassium together account for 95% of the cations whereas chloride and bicarbonate accounts for 86% of the anions

Only these electrolytes are commonly measured. Hence there is a difference between measured cations and anions. The UNMEASURED ANIONS constitute the ANION GAP which is due to protein anions, sulphate, phosphate and organic acids. Anion gap is calculated as the difference between (Na+ +K+) and (HCO3- + cl-). Normal value is 12+ 5 mmol/litre. Normal values for the Anion Gap are 8-16 mEq/L plasma Alteration in anion gap is extremely useful in the clinical assessment of patients with acid-base disorders. In acidosis, the HCO3 is reduced causing an increase in AG In hyperchloremic acidosis, there is no change in the anion gap because as a compensation, chloride ions are increased

Causes: 1. Renal disease- Inability to excrete the dietary H+ load Diminished H+ secretion Renal HCO3- loss 2. Lactic acidosis due to circulatory failure, drugs and toxins, and hereditary causes 3. Ketoacidosis - Diabetes, alcoholism, and starvation 4. Ingestions - Salicylates, methanol, ethylene glycol, isoniazide, ammonium chloride, phenformin/metformin, and hyperalimentation fluids 5. GIT HCO3- loss due to Diarrhea, Pancreatic, biliary, or intestinal fistulas 6. Renal tubular acidosis- Renal tubular cells are unable to excrete H+ efficiently, and HCO3- is lost in urine

Measuring ANION GAP - to differentiate the cause of MAc

High anion gap acidosis -increase in anion gap resulting from renal failure- excretion of H+ as well as generation of bicarbonate are deficient . Anion gap increases due to accumulation of other anions, np change in chloride level.

-Accumulation of keto acids in diabetic ketosis

-Lactic acid produces high anion gap acidosis, Normal lactic acid content in plasma is less than 2mmol/L. It is increased in tissue hypoxia, circulatory failure.

-Compensation occurs through elimination of CO2, respiratory centre responds to low pH by increasing the rate and depth of respiration (hyperventilation)
Normal anion gap -When there is loss of both anions and cations, the anion gap is normal, but acidosis may prevail. Loss of intestinal secretions as in diarrhea can lead to this type of acidosis -Hyperchloremic acidosis --may occur in renal tubular acidosis, acetazolamide (carbonic anhydrase inhibitor) therapy and uterine transplantation into large gut(bladder

Renal tubular acidosis may be due to failure to excrete acid or reabsorb bicarbonate -chloride is elevated since electrical neutrality has to be maintained In uteric transplantation, the chloride ions are reabsorbed in exchange for bicarbonate ions lost leading to hyperchloremic acidosis Acetazolamide therapy results in metabolic acidosis because HCO3- generation and H+ secretion are affected. Renal compensation occurs within 3-4 days with increased excretion of NH+ ions Associated abnormalities of potassium level are seen in cases of metabolic acidosis. Hyperkalemia is commonly seen due to redistribution of K+ and H+. Hypokalemia may result while correcting acidosis.

Clinical effects
Compensatory response is HYPERVENTILATION since increased H+ acts as stimulus- Kussmaul breathing Increased H+ leads to neuromuscular irritabilityarrhythmias leading to cardiac arrest made worse by hyperkalemia. (HYPERKALEMIA is seen due to a redistribution of K+ and H+. The intracellular K+ comes out in exchange for H+ moving into the cells) Depression of consciousness can lead to coma and death

METABOLIC ALKALOSIS
Primary excess of bicarbonate is the characteristic feature Causes : 1. Loss of acid or from the gain in base Loss of acid may result in severe vomitting or gastric aspiration leading to loss of chloride and acid, hence hypochloremic alkalosis 2.-Ingestion of large amounts of alkali Severe hypokalemia as in hyperaldosteronism( Na is retained and K is lost) and diuretic therapy (Here, H+ are retained inside cells to replace the missing K+. More H+ rather than K+ are exchanged for reabsorbed Na+. So despite alkalosis, patient passes acid urine paradoxical acid urine (Ph of the urine remains acidic- paradoxic acidosis There are two types 1. Chloride responsive: Urinary chloride is less than 10mmol/L (conditions like prolonged vomiting, nasogastric aspiration, administration of diuretics 2. Chloride resistant: urinary chloride is greater than 10mmol/l (hypertension, hyperaldosteronism, cushings syndrome)

Respiratory acidosis A primary excess of carbonic acid is the cardinal feature may be acute or chronic Acute respiratory acidosis may result from bronchopneumonia or status asthmaticus. Depression of respiratory centre due to overdose of sedatives or narcotics may also lead to hypercapnia Chronic obstructive lung disease leads to chronic respiratory acidosis Renal compensation may occur activation of carbonic anhydrase , generating more bicarbonate and excreting more H+.

Respiratory alkalosis
A primary defect of carbonic acid, hyperventilation may result in washing out of CO2 -hyperventilation can result from hysteria, raised intracranial pressure and brain stem injury Pco2 is low, Ph is high, bicarbonate level remains normal, will fall during compensation Early stage of salicylate poisonoing causes respiratory alkalosis due to stimulation of respiratory centre But later ends up in metabolic acidosis

Causes of acidosis 1. Diabetic ketoacidosis: (metabolic acidosis) and lactic acidosis 2. Respiratory acidosis in pnemonia 3. Reduced glomerular filterate

4. Addisons disease (decreased sodium and bicarbonate reabsorption)

5. Inherited renal tubular acidosis, where acid is nor excreted

6. Fanconis syndrome7. Diarrhea

Causes for alkalosis

1. Severe vomiting, CL is eliminated and compensatory increase in bicarbonate 2. Respiratory alkalosis-hyperventilation CO2 is removed and blood carbonic acid is reduced 3. Cushings syndrome sodium bicarbonate is reabsorbed from the tubules 4. Treatment of peptic ulcer is to give milk-alkali syndrome