Renal tubular acidosis: Difference between revisions
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==Background== | ==Background== | ||
* | *Class of disorders characterized by impaired reabsorption of filtered bicarbonate or excretion of hydrogen ions | ||
*Causes hyperchloremic [[metabolic acidosis]], non-anion gap | |||
*Diagnostic classification starts with low, normal, or high serum potassium | *Diagnostic classification starts with low, normal, or high serum potassium | ||
*Differentiate from [[uremia]] in which acidosis is anion gap | *Differentiate from [[uremia]] in which acidosis is anion gap | ||
==Etiologies== | ==Etiologies== | ||
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**[[Amyloidosis]] | **[[Amyloidosis]] | ||
**Drugs - ifosfamide, [[acetazolamide]] | **Drugs - ifosfamide, [[acetazolamide]] | ||
**Heavy metals ([[Lead]], mercury, copper/Wilson's) | **Heavy metals ([[Lead]], [[mercury toxicity|mercury]], [[copper toxicity|copper]]/[[wilson's disease|Wilson's]]) | ||
**[[Vitamin D deficiency]], rickets, hypophosphatemia | **[[Vitamin D deficiency]], [[rickets]], [[hypophosphatemia]] | ||
**[[Paroxysmal nocturnal hemoglobinuria]] | **[[Paroxysmal nocturnal hemoglobinuria]] | ||
**Renal transplant | **[[kidney transplant|Renal transplant]] | ||
**Fanconi's syndrome | **Fanconi's syndrome | ||
**Familial | **Familial | ||
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**[[Cirrhosis]] | **[[Cirrhosis]] | ||
**Obstructive uropathy | **Obstructive uropathy | ||
**Renal transplant | **[[kidney transplant|Renal transplant]] | ||
**Familial (decreased H+/K+-ATPase, Na+/K+-ATPase activity) | **Familial (decreased H+/K+-ATPase, Na+/K+-ATPase activity) | ||
*Type IV RTA | *Type IV RTA | ||
**Aldosterone deficiency or resistance | **Aldosterone deficiency or resistance | ||
**Diabetic nephropathy (hyporenin/hypoaldosteronism) | **[[Diabetic nephropathy]] (hyporenin/hypoaldosteronism) | ||
**Obstructive uropathy | **Obstructive uropathy | ||
**Chronic tubulointerstitial disease | **Chronic tubulointerstitial disease | ||
**Potassium-sparing diuretics | **Potassium-sparing [[diuretics]] | ||
**Heparin induced adrenal insufficiency | **[[Heparin]] induced [[adrenal insufficiency]] | ||
==Differential Diagnosis== | |||
*See [[metabolic acidosis]] | |||
==Workup== | |||
*[[ABG]] or [[VBG]] | |||
*BMP, phos, mag | |||
*Urine pH | |||
*Urine electrolytes - Na, K, Cl, Ca, Cr | |||
*Plasma aldosterone and cortisol for type IV RTA | |||
*Note that when hyperkalemia is present, aldosterone should be elevated, so a "normal" aldosterone level may be relatively low | |||
==Features and Treatment== | ==Features and Treatment== | ||
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*For type I and II RTA, treat all children and infants | *For type I and II RTA, treat all children and infants | ||
**Generally, 5-15 mEq/kg/day oral bicarbonate | **Generally, 5-15 mEq/kg/day oral bicarbonate | ||
**May require IV bicarbonate for severe acidosis | **May require IV [[bicarbonate]] for severe acidosis | ||
**PO potassium supplements | **PO [[potassium]] supplements | ||
**Treat adults with bicarb < 18-20 mEq/L | **Treat adults with bicarb < 18-20 mEq/L | ||
**Treat underlying d/o (Vitamin D, etc.) | **Treat underlying d/o (Vitamin D, etc.) | ||
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**Urine pH < 5.5 | **Urine pH < 5.5 | ||
*Serum aldosterone and cortisol levels to determine between: | *Serum aldosterone and cortisol levels to determine between: | ||
**Adrenal insufficiency, Addison's (low aldosterone, low cortisol) | **[[Adrenal insufficiency]], [[addison's disease|Addison's]] (low aldosterone, low cortisol) | ||
**Selective aldosterone deficiency (low aldosterone, normal cortisol) | **Selective aldosterone deficiency (low aldosterone, normal cortisol) | ||
**Aldosterone resistance (nl to high aldosterone, nl to high cortisol) | **Aldosterone resistance (nl to high aldosterone, nl to high cortisol) |
Revision as of 16:38, 29 September 2019
Background
- Class of disorders characterized by impaired reabsorption of filtered bicarbonate or excretion of hydrogen ions
- Causes hyperchloremic metabolic acidosis, non-anion gap
- Diagnostic classification starts with low, normal, or high serum potassium
- Differentiate from uremia in which acidosis is anion gap
Etiologies
- Type II RTA
- Multiple myeloma
- Amyloidosis
- Drugs - ifosfamide, acetazolamide
- Heavy metals (Lead, mercury, copper/Wilson's)
- Vitamin D deficiency, rickets, hypophosphatemia
- Paroxysmal nocturnal hemoglobinuria
- Renal transplant
- Fanconi's syndrome
- Familial
- Primary metabolic (cystinosis, von Gierke's)
- Type I RTA
- Autoimmune - Sjögren, SLE, RA
- Drugs - Lithium, amphotericin B, ifosfamide
- Sickle cell disease
- Cirrhosis
- Obstructive uropathy
- Renal transplant
- Familial (decreased H+/K+-ATPase, Na+/K+-ATPase activity)
- Type IV RTA
- Aldosterone deficiency or resistance
- Diabetic nephropathy (hyporenin/hypoaldosteronism)
- Obstructive uropathy
- Chronic tubulointerstitial disease
- Potassium-sparing diuretics
- Heparin induced adrenal insufficiency
Differential Diagnosis
Workup
- ABG or VBG
- BMP, phos, mag
- Urine pH
- Urine electrolytes - Na, K, Cl, Ca, Cr
- Plasma aldosterone and cortisol for type IV RTA
- Note that when hyperkalemia is present, aldosterone should be elevated, so a "normal" aldosterone level may be relatively low
Features and Treatment
- Mild acidosis in adults with bicarb > 20 mEq/L may not require treatment
- Children should be treated due to impaired growth
- For type I and II RTA, treat all children and infants
- Generally, 5-15 mEq/kg/day oral bicarbonate
- May require IV bicarbonate for severe acidosis
- PO potassium supplements
- Treat adults with bicarb < 18-20 mEq/L
- Treat underlying d/o (Vitamin D, etc.)
Proximal Tubular Acidosis
- Type II RTA - reduced bicarbonate reabsorption
- Hypokalemia
- Serum bicarb 12-20 mEq/L generally
- Urine pH < 5.5, but can be variable
- Urine pH > 5.5 if undergoing alkali therapy
Distal Tubular Acidosis
- Type I RTA - impaired H+ and ammonium secretion
- Hypokalemia
- Normokalemia may be seen in chronic interstitial renal disease
- Serum bicarb may be < 10 mEq/L
- Urine pH > 5.5
- Urinary anion gap > 50 mEq/L = Na + K - Cl
- Nephrolithiasis, calcium stones from chronic acidosis causing bone resorption and hypercalciuria
- Hypokalemia
Type IV RTA
- Also distal tubular acidosis
- Hyperkalemia
- Mild acidosis, with bicarb generally > 17 mEq/L
- Urine pH < 5.5
- Serum aldosterone and cortisol levels to determine between:
- Adrenal insufficiency, Addison's (low aldosterone, low cortisol)
- Selective aldosterone deficiency (low aldosterone, normal cortisol)
- Aldosterone resistance (nl to high aldosterone, nl to high cortisol)
References
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock. Renal Tubular Acidosis Syndromes. South Med J. 2000;93(11). http://www.medscape.com/viewarticle/410658.
- UCSF Education. Renal Tubular Acidosis. Nov 2002. https://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/renal%20tubular%20acidosis.pdf.