0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16
976 Metabolic Acidosis
acidosis due to gastrointestinal-ureteral connections can be
improved by minimizing urine contact time and bowel surface
area in contact with urine
oral NaHCO3 tablets
➣renal acidosis
type I hypokalemic distal RTA
treat underlying cause
administer HCO3 or citrate in an amount to equal daily acid
production (1 mEq/kg/d)
treat hypokalemia prior to or at same time as HCO
3<admin-
istration to avoid worsening hypokalemia
K citrate corrects acidemia, hypokalemia and lessens long
term risk for nephrolithiasis
type II proximal RTA
treat underlying cause if possible
difficult to correct acidosis, administered HCO3 is rapidly
lost in urine and contributes to increased renal K loss
therapy consists of oral HCO3, thiazide diuretic to induce
volume contraction, K sparing diuretic, oral K
frequent monitoring of serum electrolytes required
vitamin D therapy required to prevent rickets or osteomala-
cia
type IV hyperkalemic distal RTA
treatment dependent on underlying cause
adrenal failure is treated with appropriate hormone replace-
ment therapy
in setting of renal insufficiency treatment dependent upon
blood pressure
➣normotensive: fludrocortisone (complicated by Na retention)
➣hypertension: K restricted diet, loop diuretics, NaHCO3 tablets
RTA of renal insufficiency
HCO3 in an amount to equal daily acid production (1
mEq/kg/d) will correct acidosisfollow-up
■high anion gap acidosis
➣once underlying cause is corrected no specific follow up is needed
■normal anion gap acidosis
➣if long term therapy required keep HCO 3 near normal (22–24
mEq/L) to avoid long term complications of acidemia
➣monitor K closely if receiving K replacement