Acid-Base Compensation: What is it, and how to prevent it?

Acid-base Compensation is the relative constancy of the acid-base relationship of the internal environment of a living organism, particularly when it comes to the renal system. Also called acid-base balance, acid-base balance, equilibrium of acids and bases. It is an integral part of homeostasis. Quantitatively it is characterized either by the concentration of hydrogen ions in moles per one liter or by the hydrogen pH. The tissues of a living organism are very sensitive to fluctuations in the pH value – outside the permissible range, protein denaturation occurs: cells are destroyed, enzymes lose their ability to perform their functions, and the body can die. Therefore, the acid-base balance in the body is tightly regulated. There are several buffer systems that reversibly bind hydrogen ions and prevent any changes in pH. The bicarbonate buffer system (the most powerful and most controllable among buffer systems) is particularly important: an excess of protons interacts with bicarbonate ions (metabolic alkalosis) to form carbonic acid. Further decrease in the amount of carbonic acid occurs as a result of an accelerated release of carbon dioxide as a result of hyperventilation of the lungs (concentration is determined by the pressure in the alveolar gas mixture.)

There are several approaches for the evaluation and classification of acid-base balance alterations. The physicochemical proposal is the most recent and is based on the difference of strong ions, the total concentration of weak plasma acids and the partial pressure of arterial carbon dioxide. Of great acceptance among anesthesiologists and intensivists, it is a tremendous complex approach, both technical and interpretation. Therefore, in this post, the physiological approach will be used, based on pH, and plasma bicarbonate, which is the simplest, most rigorous and practical way to systematically classify and treat alterations in the acid-base balance.

First of all acid-base disorder must answer three basic questions. The first has to do with what disorder it is. The second, if the secondary response is adequate. The third, about the cause of the disorder. Metabolic acidosis is divided according to the value of the anionic hiatus. Acidosis with increased anionic hiatus: acid gain, endogenous or exogenous, predominates. They are normochloremic acidosis. Acidosis with normal anionic hiatus: the loss of bicarbonate outside the body predominates. They are called hyperchloremic acidosis.

Approximately three-quarters of the value of the anion hiatus correspond to serum albumin, which is an anion, so in the assessment of the anion, hiatus should be taken into account if hypoalbuminemia, as well as other circumstances.

The acid-base balance of the organism is possible thanks to the interrelation of three systems: intracellular and extracellular tampons, which cushion in a minute the acute changes of acid-base balance; respiratory compensation, which starts in minutes and is completed in hours, and renal excretion of excess acids, which takes more time. The total buffer capacity of the organism is about one thousand mMol (forty percent in the extracellular space, and sixty in the intracellular space.)

To plan an adequate treatment, and as in any acid-base disorder, it is essential to identify secondary responses (compensation mechanisms), whether these are adequate or not, and whether there are other acid-base mixed disorders or associated electrolyte disorders.

Read also: How to reduce the chances of suffering renal failure, by Joe Cosgrove

In metabolic acidosis, the key aspect of treatment lies in blocking the source of acid production (eg, by providing insulin in diabetic ketoacidosis,) always taking into account the compensations that exist, the rate of acid production and its cause (lactic acidosis due to hypoxia or alcohol intoxication are more serious due to its rapid evolution.) Special caution when planning treatment deserves the detection of hypokalemia since it implies a serious potassium deficit. The replacement of bicarbonate should be very cautious, applied only in certain circumstances (eg, extreme hyperkalemia, potentially fatal drops in pH,) and always assessing the risks and benefits. The only objective is to gain time until the homeostatic mechanisms manage to increase the pH.

To the problem of acidosis due to keto acids caused by insulin deficiency, water deficit, circulating volume deficit, the coexistence of lactic acidosis and potassium deficit, which in turn depends on the duration and magnitude of polyuria secondary to poor glycemic control, and the degree of replacement of losses.

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Image courtesy of pixabay.com at Pexels.com

The general treatment plan should include, therefore: Insulin, re-expansion of the extracellular volume, correction of possible potassium deficit, and the decision to administer or not bicarbonate should be valued with great caution. The alterations in the bicarbonate concentration or the partial pressure of carbon dioxide in the arterial blood are accompanied by a compensatory response in the other element. If the compensation is adequate or it will not allow detecting if there is a second or third associated disorder, in what constitute the mixed disorders that are very frequent in clinical practice and that implies a greater severity.

In order to detect mixed disorders, it must be taken into account that a compensation will never be able to normalize the pH. Its treatment and the priority of the actions to follow will depend on the cause and predominant acid-base disorder, always taking into account the associated electrolyte alterations.

Recommended: Acid-Base Disorders

* Featured Image courtesy of Pixabay at Pexels.com

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Unique Advantages of Proplete Nutritional Supplement

Joe Cosgrove is the CEO of Pentec Health Incorporated, a specialty sterile compounding pharmacy providing services to patients in the home and other various alternate administration sites. The company is located in Boothwyn, Pennsylvania. Also the chairman of Pentec Health’s board, Joe Cosgrove manages the company’s development strategy and is largely responsible for its newest line of dietary supplements known as Proplete.

Due to its unique composition, Proplete, designed for those who experience problems after hemodialysis, provides benefits to patients with the following conditions:

Chronic Kidney Disease: An estimated 70 percent of patients with chronic kidney disease deal with malnutrition after receiving hemodialysis, which can lead to weight loss and low protein levels. Proplete provides significant doses of protein.
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Fluid Management Problems: Patients with advanced cardiac or hepatic disease may experience problems with managing fluids. The low-volume nature of Proplete can help alleviate these concerns.

Obesity: Traditional hemodialysis medications often contain extra calories and lipids in addition to high levels of protein. Proplete contains no lipids and is low in carbohydrates, making it ideal for overweight or obese patients.

Diabetes: Many Intradialytic Parenteral Nutrition (IDPN) supplements require close supervision of blood glucose intake in diabetic patients. The low-dextrin formula of Proplete allows diabetic patients to more easily manage these levels.

Dialysis: Almost 70 decades of hard work and progress

Like many other medical procedures and aids, dialysis has been around for a while. For the past 70 decades, it has helped thousands (if not millions) of individuals whose kidneys stopped working properly.

Kidneys can fail due to a wide variety of reasons. Sometimes genetics get in the way and make them stop working, or certain environmental conditions or experiences change the way they work and lead individuals to a kidney failure or a chronic kidney disease. This has happened to humans for as long as they have existed and it will probably keep on happening for as long as we are on earth.

Regardless the reason why kidneys fail, for those whose bodies are not able to filter the waste that runs in the blood, undergoing dialysis procedures becomes necessary.

Nowadays, this is a solution easy to picture. But, has anyone asked how we managed to make it until this point? Years of sacrifice and medical progress had to get in the way for us to be able to know dialysis as it works today.

In this article, Joe Cosgrove will share some historical facts related to dialysis.

Back in the 40’s

Dialysis is a 20th-century invention. It was first invented by Dr. Willem Kolff back in 1943 when this young doctor from the Netherlands decided to construct the first artificial kidney or dialyzer.

The process of developing this kidney was long and took Dr. Kolff more than 10 years. It started when he was a student at the University of Groningen Hospital, in his natal country. Kolff watched how a young man died in a painful and slow way because his kidneys fail and there was nothing to be done. This situation inspired Kolff and moved him to create an artifact that could work as the kidneys.

Kolff read every book available at the University’s library that talked about the kidneys and how the filtered waste from the blood. This is how bumped into an article written in 1913 by a famous pharmacologist named John Abel. In this article, Abel described the hemodialysis process in animals. Abel’s work inspired Kolff to create an artificial kidney.

When Kolff was doing his first experiments, the World War II started, forcing him to work at a Dutch hospital in a remote location once the Nazis overtook the country. This hard conditions never stopped him and he kept on working on the artificial kidney project.

kolff artificial kidney 1946_dializer_dialysis

Image courtesy of rob koopman at Flickr.com

Eventually, he came up with a device made with sausage skin, a washing machine, orange juice cans and other items that would allow him to filter waste from the blood. His invention took place under the Nazi domain and risking his life to make it possible.

By 1943, Kolff’s kidney was finished and ready to be tested. Until 1945, 16 patients were treated unsuccessfully. It wasn’t until that same year that a woman with a uremic coma was successfully treated and regained consciousness.

This is how Kolff’s dialyzer became the first one in history successfully used to treat kidney diseases. It became part of the standard treatment for kidney failure for the next 10 years.

There is hope in the 50’s

In the years to come, Kolff’s invention was improved to treat both acute renal failure and chronic stage renal disease. This was a rough path since most doctors in the 50’s believed that patients with kidney problems couldn’t undergo dialysis for long periods of time and that no man could come up with an artificial kidney that could replace the functions of a real one.

Another challenge that had to be faced back then was the strong damage veins and arteries of patients were suffering. This makes hard for patients to take the treatment for long periods of time.

It wasn’t until Professor Dr. Belding Scribner at the University of Washington came up with the idea of connecting plastic tubes to the dialyzer, and inserting one of these tubes into the patient’s arteries and veins, that would remain open for as long as the treatment lasted. These tubes had the shape of a U that would work as a bypass.

Later in time, this device was improved with a new material called Teflon and operated as a dialysis bypass that allowed patients to be treated for longer periods of time, extending their lives until an organ was available for a transplant.

From the 60’s to today

Dialysis Machine_Dialysis on children_joe cosgrove

Image courtesy of Amber Case at Flickr.com

Dialysis patients became numerous and facilities couldn’t serve all of them. Committees would decide who was going to dialysis and who had to wait. This is how bioethics committees were created and healthcare treatments became fairly available for many individuals who needed them. Portable dialysis machines were created and people could undergo dialysis at their homes.

During the past five decades, dialysis machines have been improved by technology. Kidney medicine has also evolved in a way kidney conditions can be treated with multiple alternatives. Some people use the peritoneal dialysis treatment and some other decide to undergo the hemodialysis one. Regardless the options, it is thanks to doctors like Kolff and Scribner that dialysis treatment became real.