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metabolic alkalosis

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Information about metabolic alkalosis
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Published on January 30, 2009

Author: ymaurya20

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METABOLIC ALKALOSIS : ynm dduh new delhi 64 METABOLIC ALKALOSIS By Dr Y.N MAURYA M.B.B.S, D.C.H Medical Officer Deen Dayal Upadhyay Hospital Govt. of NCT New Delhi- 64 CONDITIONS CAUSING SUSTAINED METABOLIC ALKALOSIS : ynm dduh new delhi 64 CONDITIONS CAUSING SUSTAINED METABOLIC ALKALOSIS STRONG STIMULUS TO REABSORB SODIUM ( hypovolumia) INCREASED SECRETION OF H+ BY RENAL TUBULE 1)Loop diuretics 2)High PaCO2 3)Tubular cell K+ depletion 4)Increased mineralocorticoid activity METABOLIC ALKALOSIS - CAUSES : ynm dduh new delhi 64 METABOLIC ALKALOSIS - CAUSES Cl¯ Responsive (urinary Cl¯<15 meq/L) Cl¯ Resistant (urinary Cl¯>20 meq/L) HIGH BP NORMAL BP 1) Gastric losses 2) Loop diuretics (frusemide) 3) Cl¯ loosing diarrhoea 4) Cl¯ Deficient formula 5) Cystic fibrosis 6) Post hypercapnoea 1) Adrenal adenoma/hyperplasia 2) Hyperaldosteronism(remedial) 3) Renovascular disease 4) Renin secreting tumor 5) 17 alfa hydro.deficiency 6) 11 beta hydro.deficiency 7) Cushing syndrome 8) 11 beta hydroxysteriod dehydrogenase deficiency 9) Licorice ingestion 10) Liddle syndrome Gitelman syndrome Bartter syndrome Excess base intake METABOLIC ALKALOSIS METABOLIC ALKALOSIS- PATHOPHYSIOLOGY : ynm dduh new delhi 64 METABOLIC ALKALOSIS- PATHOPHYSIOLOGY VOMITING LOOP DIURETIC e.g furosemide,bumetanide K+ LOSS H+ LOSS Na+ & Cl¯ LOSS Block Na+ reabsorption ECF volume Renin Angiotensin-2 Aldosterone Loop of henle Distal tubule Shift of H+ into cells Na+ delivery to distal tubule Reabsorption of Na+ in exchange for H+ i.e loss of H+ Plasma HCO3¯ METABOLIC ALKALOSIS METABOLIC ALKALOSIS- PATHOPHYSIOLOGY : ynm dduh new delhi 64 METABOLIC ALKALOSIS- PATHOPHYSIOLOGY Cl¯ lossing diarrhoea AR/mutation in Cl¯/HCO3¯ exchange pump carrier protein located on CHR-7 Distal ileum & colon mother baby HCO3¯ in blood diarrhoea Metabolic alkalosis Cl¯ loss in stool Volume loss Stool Cl¯ hypochloremia aldosterone Hypokalemia Met. alkalosis polyhydramnios METABOLIC ALKALOSIS- PATHOPHYSIOLOGY : ynm dduh new delhi 64 METABOLIC ALKALOSIS- PATHOPHYSIOLOGY Cystic fibrosis Mutation in CF gene on CHR-7 (del 3 bp in CFTR protein ) Na+ & Cl¯ loss Volume depletion Hrponatremia (rare) alkalosis hypokalemia Cl¯ RESISTANT METABOLIC ALKALOSIS ( B P) PATHOPHYSIOLOGY : ynm dduh new delhi 64 Cl¯ RESISTANT METABOLIC ALKALOSIS ( B P) PATHOPHYSIOLOGY Adrenal adenoma aldosterone Mineralocorticoid activity Na+ retention Excretion of H+ LOSS OF k+ Hypokalemia Alkalosis Hypertention Renovascular disease Renin secreting tumor Renin cortisol 11 beta hyroxysteroiod dehydrogenase deficiency Licorice Aldosterone synthase 18 OH Corticosterone CAH 17 alfa hydroxylase defic. 11 beta hydroxylase defic. Bartter syndrome PATHOPHYSIOLOGY : ynm dduh new delhi 64 Bartter syndrome PATHOPHYSIOLOGY Bartter syndrome ( AR) Antenatal (hyper PGE synd.) Classic Bartter syndrome Mutation in luminal K+ CHANNEL Mutation in Na+ K+ 2Cl¯ transporter Mutation in basolat. Cl¯ channel Defect in Na+ K+ resorption in ascending loop of henle Volume contraction Activatioin of renin-angiot 2- aldost. axis Hypokalemia (<2.5 meq/L) alkalosis Hypomagnesemia (> in Gitelman synd.) Urinary loss of K+ Cl¯ hypercalciuria nephrocalcinosis Present in infancy Present in childhood polyhydramnios Dysmor.Feature Triangular face Protruding ear Large eye strabismus Drooping mouth Suspect when severe hypokalemia with met alkalosis RENIN , ALDOSTERONE. PGE (antenatal) IN SERUM GITELMAN SYNDROME PATHOPHYSIOLOGY : ynm dduh new delhi 64 GITELMAN SYNDROME PATHOPHYSIOLOGY GITELMAN SYNDROME (autosomal recessive) Mutation in thiazide sensitive Na+ Cl¯ co-transpoprter in DCT Na+ resorption in in DCT HYPOVOLUMIA Alkalosis hypomagnesemia Tubular absorption of calcium hypocalciuria Hypokalemia Present in late childhood or early adulthood C/O– weakness , fatigue Nocturia, recurrent muscle cramp/spasm SERUM RENIN & ANGIOTENSIN LEVEL INCREASED. PGE NORMAL RX potassium, magnesium supplementation, K+ sparing diuretics No role of NSAID and ACE inhibitor METABOLIC ALKALOSIS- HISTORY TAKING : ynm dduh new delhi 64 METABOLIC ALKALOSIS- HISTORY TAKING vomiting, medication diuretics in CHF Salty sweats – CYSTIC FIBROSIS Intake of sodabicarb. Massive blood transfusion, citrate bicarbonate Total parenteral nutrition (TPN) acetate bicarbonate POLYHYDRAMNIOS IN MOTHER antenatal Bartter syndrome Deafness Bartter syndrome Hypertention hypermineralocorticoid state Recurrent dehydration Bartter syndrome METABOLIC ALKALOSIS- INVESTIGATIONS : ynm dduh new delhi 64 METABOLIC ALKALOSIS- INVESTIGATIONS Electrolyte and ABG Urinary chloride Renin & aldosterone renovascular HTN,renin secret. tumor Renin & aldosterone adrenal adenoma, glucocort. Remedial hyperaldostero. Renin & aldosterone cushing & Liddle synd. Licorice, 17 alfa hydro.deficiency 11 beta hydro.deficiency 11 beta hydroxysteriod dehydrogenase deficiency Elevated 24 hr urine cortisol Cushing syndrome Elevated 11 de-oxycortisol 17 alfa hydro.deficiency, 11 beta hydro.deficiency METABOLIC ALKALOSIS- TREATMENT : ynm dduh new delhi 64 METABOLIC ALKALOSIS- TREATMENT Remove the cause Mild metabolic alkalosis (HCO3 <32 mmol/L) usually no Tt. Tt. required if--worsening metabolic alkalosis (nasogastric suction), both resp. and metabolic alkalosis are present. Intervention is necessary in mod- severe cases nasogastric suction continued ----- PPIS AVOID DIURETICS if necessary give potassium sparing diuretics with potassium supplementation Arginine HCl– to treat Cl¯ responsive metabolic alkalosis potassium & sodium are increased Severe metabolic alkalosis ---- acetazolamide C.I in volume depletion and hypokalemia METABOLIC ALKALOSIS- TREATMENT : ynm dduh new delhi 64 METABOLIC ALKALOSIS- TREATMENT Cl¯ Responsive metabolic alkalosis-- volume depletion Aim should be to eliminate excess aldosterone effect Renovascular-----repaired Adenoma---resected Licorice---eliminate 17 alfa hydro.deficiency 11 beta hydro.deficiency give glucocorticoid 11 beta hydroxysteriod dehydrogenase deficiency--spironolactone METABOLIC ALKALOSIS- TREATMENT : ynm dduh new delhi 64 METABOLIC ALKALOSIS- TREATMENT Liddle syndrome — amiloride / triamterene Bartter’s syndrome--potassium sparing diuretics with potassium supplementation and NSAIDS GITELMAN SYNDROME potassium sparing diuretics with potassium and magnesium supplementation. Slide 15: ynm dduh new delhi 64 THANK YOU

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