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CPC Conference February 8, 2005. James P. Knochel, MD. Did this patient have alcoholic ketoacidosis?. Acute metabolic acidosis and CNS syndrome could result from AKA and thiamine deficiency. Ruled out by lack of ketones and normal lactate in blood Treat with thiamine anyway.
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CPC Conference February 8, 2005 James P. Knochel, MD
Did this patient have alcoholic ketoacidosis? • Acute metabolic acidosis and CNS syndrome could result from AKA and thiamine deficiency. • Ruled out by lack of ketones and normal lactate in blood • Treat with thiamine anyway
Was this patient phosphorus deficient? • Intake? No supplement • 100 lb. Weight loss • Malabsorption? • CHO yes! • Fat? • Serum P = 2.4 (despite acidosis), Mg++ 1.2, Ca++ normal
Renal Excretion of Acid in Normal Persons Three renal mechanisms: • Acidification of urine • Na2H PO4 + H+ NaH2PO4 (Na _____H exchange) • NH3 + H+NH4
What does PO4 deficiency do to acid-base balance? Urine PO4 falls to zero: Therefore no Na2HP4 + H+ NaH2PO4 Renal NH3 production falls Therefore decrease NH3 + H NH4
PO4 Deficiency in Normal Person Causes • Hypercalciuria • Hypercalcemia under certain conditions • Hydrogen exchanged for bone CO3 • No net change in acid/base status • Dependent on PTH, Mg and Vit D
PO4 Deficiency in Patient with Unresponsive Bone • No change in Ca++ excretion • No bone buffering • No avenue to excrete metabolic acid • Metabolic acidosis results • Reported in lactase deficiency and Ricketts
Did phosphorus deficiency in this patient contribute to metabolic acidosis? • Mg deficiency suppresses bone mobilization • PTH deficiency suppresses bone mobilization • Vit D deficiency suppresses bone mobilization
D-lactic acidosis Clinical Syndrome • Metabolic acidosis with anion gap • Neurological symptoms • Nystagmus, ophthalmoplegia, ataxia, confusion, inappropriate behavior
D-lactic acidosis • Short bowel syndrome with intact colon • Ischemic bowel • Carbohydrate load colon pH (scfas and acetate) • Colon pH bacterioides,lactobacilli, etc • Acid tolerant flora produces D-lactic acid • D-lactic acid absorbed and metabolized
Factors other than metabolic acidosis in this case • Hypernatremia, hyperchloremia with very low BUN and creatinine • ? Nephrogenic DI due to K+ deficienty • K+ = 2.4 despite metabolic acidosis? • Poor intake, chronic diarrhea • Polyuria despite volume depletion • No K+ supplements
