Acidosis hyperkalemia caused

Although there is a long list of causes of metabolic acidosis with an increased anion gap (286,287), clinical clues can help diagnosis. A case report has illustrated the acute metabolic and hemodynamic effects of ingestion of a massive load of oral citric acid. The principal findings included a metabolic acidosis accompanied by an increase in the plasma anion gap, not due to lactic acidosis, hyperkalemia, and the abrupt onset of hypotension (288). 

Patients with acute hyperkalemia usually require other therapies to manage hyperkalemia until dialysis can be initiated. Patients who present with cardiac abnormalities caused by hyperkalemia should receive calcium gluconate or chloride (1 g intravenously) to reverse the cardiac effects. Temporary measures can be employed to shift extracellular potassium into the intracellular compartment to stabilize cellular membrane effects of excessive serum potassium levels. Such measures include the use of regular insulin (5 to 10 units intravenously) and dextrose (5% to 50% intravenously), or nebulized albuterol (10 to 20 mg). Sodium bicarbonate should not be used to shift extracellular potassium intracellularly in patients with CKD unless severe metabolic acidosis (pH less than 7.2) is present. These measures will decrease serum potassium levels within 30 to 60 minutes after treatment, but potassium must still be removed from the body. Shifting potassium to the intracellular compartment, however, decreases potassium removal by dialysis. Often, multiple dialysis sessions are required to remove potassium that is redistributed from the intracellular space back into the serum. 

During phase I, each seizure causes a sharp increase in autonomic activity with increases in epinephrine, norepinephrine, and steroid plasma concentrations, resulting in hypertension, tachycardia, hyperglycemia, hyperthermia, sweating, and salivation. Cerebral blood flow is also increased to preserve the oxygen supply to the brain during this period of high metabolic demand. Increases in sympathetic and parasympathetic stimulation with muscle hypoxia can lead to ventricular arrhythmias, severe acidosis, and rhabdomyolysis. These, in turn, could lead to hypotension, shock, hyperkalemia, and acute tubular necrosis. 

SuccessM treatment of PEA and asystole depends almost entirely on diagnosis of the underlying cause. Potentially reversible causes include (1) hypovolemia, (2) hypoxia, (3) preexisting acidosis, (4) hyperkalemia, (5) hypothermia, (6) hypoglycemia, (7) drug overdose, (8) cardiac tamponade, (9) tension pneumothorax, (10) coronary thrombosis, (11) pulmonary thrombosis, and (12) trauma. 

There is evidence that y-aminobutyric acid A receptors may be modified during SE and become less responsive to endogenous agonists and antagonists. Two phases of GCSE have been identified. During phase I, each seizure produces marked increases in plasma epinephrine, norepinephrine, and steroid concentrations that may cause hypertension, tachycardia, and cardiac arrhythmias. Muscle contractions and hypoxia can cause acidosis, and hypotension, shock, rhabdomyolysis, secondary hyperkalemia, and acute tubular necrosis may ensue. 

Seizures, muscular hyperactivity, and rigidity may result in death. Seizures may cause pulmonary aspiration, hypoxia, and brain damage. Hyperthermia may result from sustained muscular hyperactivity and can lead to muscle breakdown and myoglobinuria, renal failure, lactic acidosis, and hyperkalemia. Drugs and poisons that often cause seizures include... 

Severe adverse drug reactions with trimethoprim and co-trimoxazole are rare (12-14). This also applies to children (15). The adverse effects of co-trimoxazole correspond to those expected from a sulfonamide (16). In HIV-infected patients, adverse effects of co-trimox-azole are more frequent and more severe (17-19). Hematological disturbances due to co-trimoxazole include mild anemia, leukopenia, and thrombocytopenia, which may be due to folic acid antagonism. Serious metabolic disturbances that are associated with trimethoprim include hyperkalemia and metabolic acidosis. Trimethoprim can cause hypersensitivity reactions. However, with co-trimoxazole, the sulfonamide is generally believed to be more allergenic (12). Generalized skin reactions predominate. Other effects, such as anaphylactic shock, are extremely rare (20-22). Carcinogenicity due to trimethoprim or co-trimoxazole has not been reported. 

Spironolac- tone 100 mg/day 300 mg/day 25% 100% 100% Avoid Active metabolites with long half-life hyperkalemia common when GFR < 30 ml/min, especially in diabetics may cause gynecomastia and hyperchloremic acidosis increases serum by immunoassay interference No data No data Avoid... 

The transfer of intracellular K" into ECF invariably occurs in acidosis as H shifts intraceHularly and shifts outward to maintain electrical neutrality. As a general rule, K concentrations are expected to rise 0.2 to 0.7 mmol/L for every 0.1 unit drop in pH. When the underlying cause of the acidosis is treated, normokalemia will rapidly be restored. Extracellular redistribution of may also occur in (1) dehydration, (2) shock with tissue hypoxia, (3) insulin deficiency (e.g., diabetic ketoacidosis), (4) massive intravascular or extracorporeal hemolysis, (5) severe burns, (6) tumor lysis syndrome, and (7) violent muscular activity, such as that occurring in status epilepticus. Finally, important iatrogenic causes of redistribution hyperkalemia include digoxin toxicity and P adrenergic blockade, especially in patients with diabetes or on dialysis. ... 

Failure of the kidneys to synthesize renin, failure of the adrenal cortex to secrete aldosterone, and renal tubular resistance to aldosterone are the most common causes of this type of acidosis (often called type IV RTA). This inhibits Na" reabsorption, and both and are thus abnormally retained. The result is decreased renal ammonia formation and therefore decreased elimination of H. If associated with increased ECF volume, HCO3 reclamation in the tubules may be depressed. There is usually an associated mild renal msuf-ficiency (elevated serum creatinine), but urine may stiU be acidified to a pH <5.5. Hyperkalemia is also usually present. 

Hyperkalemia may occur in renal disease and adrenal insufficiency owing to impairment of normal secretory mechanisms. Metabolic acidosis, in particular diabetic acidosis, and catabolism of cellular protein in starvation or fever cause K+ release from cells. Treatment consists of correction of the acidosis and promotion of cellular uptake of K+ by administration of insulin, which enhances glucose intake. In severe cases, ion exchange resins given orally bind K+ in intestinal secretions. 

In addition to CKD as a risk factor, other contributing factors should also be considered. This includes exposure to potassium-sparing diuretics -blockers, which work predominantly via 82-antagonistic effects to interfere with the extrarenal translocation of potassium into cells and ACEls, which may cause hyperkalemia by reducing aldosterone production. Polycitra, used for the treatment of metabolic acidosis, contains potassium citrate and should not be prescribed for patients with severe CKD. If hyperkalemia develops, management options are based on the degree to which potassium is elevated (see Chap. 50). 

Gastrointestinal symptoms of metabolic acidosis include loss of appetite, nausea, and vomiting. Severe acidosis (pH <7.1) interferes with carbohydrate metabolism and insulin utilization, and results in hyperglycemia. Metabolic acidosis alters potassium homeostasis and contributes to the development of hyperkalemia. The magnimde of the effect on serum potassium depends on the type of acidosis Acidosis caused by mineral acids (e.g., hydrochloric acid) are associated with a greater change in potassium levels than acidosis caused by organic acids (e.g., lactic acidosis), in which the increase in potassium attributable to the acidosis per se is minimal. 

Seizure-induced muscular contractions and hypoxia cause lactic acid release that can produce a severe acidosis that may be accompanied by hypotension and shock. Muscle contractions can be so severe that rhabdomyolysis with secondary hyperkalemia and acute tubular necrosis may occur. The airway may be obstructed, and the patient may become cyanotic or hypoxic at any time. Additionally, an increase in salivation and tracheal and pulmonary secretions may result in aspiration pneumonia. Although transient pleocytosis (i.e., white blood cell counts up to 20,000/mm ) may develop, it should not be attributed to GCSE until infectious causes have been eliminated. 

Spironolactone (aldosterone receptor antagonist) and amiloride and triamterene (Na+ channel blockers) prevent the above effects, leading to minor effects on Na+ reabsorption but major effects on the retention of K+ ions and protons. Thus, they cause small increases in urinary Na+ and marked decreases in urinary K+, resulting in hyperkalemia and acidosis. 

As with other K+-sparing diuretics, MR antagonists may cause life-threatening hyperkalemia. Indeed, hyperkalemia is the principal risk of MR antagonists. Therefore, these drugs are contraindicated in patients with hyperkalemia and in those at increased risk of developing hyperkalemia either because of disease or because of administration of other medications. MR antagonists also can induce metabolic acidosis in cirrhotic patients. 

Some causes of hyperkalemia and hypokalemia are listed in Table 6.1. Increases of plasma potassium may be observed following metabolic acidosis, severe tissue... 

These actions on electrolyte transport, in the kidney and in other tissues e.g., colon, salivary glands, and sweat glands), appear to account for the physiological and pharmacological activities that are characteristic of mineralocorticoids. Thus, the primary features of hyperaldosteronism are positive Na balance with consequent expansion of extracellular fluid volume, normal or slight increases in plasma Na+ concentration, hypokalemia, and alkalosis. Mineralocorticoid deficiency, in contrast, leads to Na+ wasting and contraction of the extracellular fluid volume, hyponatremia, hyperkalemia, and acidosis. Chronically, hyperaldosteronism can cause hypertension, whereas aldosterone deficiency can lead to hypotension and vascular collapse. 

Uses Chronic metabolic acidosis, alkahnize urine dissolve uric acid cysteine stones Action Urinary alkahnizer Dose Adults. 2-6 tsp (10-30 mL) diluted in 1-3 oz H2O pc hs Peds. 1-3 tsp (5-15 mL) diluted in 1-3 oz H2O pc hs best after meals Caution [C, -h] Contra Al-based antacids severe renal impair or Na restricted diets Disp Liq SE Tetany, metabolic alkalosis, T GI upset avoid use of multiple 50-mL amps can cause T NaMiyperosmolality Interactions T Effects OF amphetamines, ephedrine, flecainide, pseudoephedrine, quinidine 4 effects OF barbitm ates, chlorpropamide, Li, salicylates EMS Monitor ECG for hyperkalemia (peaked T waves) OD May cause convulsions, muscle twitching, tetany, and Szs symptomatic and supportive... 

Complications. The earliest complication of acute renal failure is hyperkalemia (see p 38) this may be more pronounced if the cause of the renal failure is rhabdomyolysis or hemolysis, both of which release large amounts of Intracellular potassium into the circulation. Later complications include metabolic acidosis, delirium, and coma. 

---