A chapter by chapter recap of Burton Rose’s classic, The Clinical Physiology of Acid Base and Electrolyte Disorders, a kidney physiology book for nephrologists, fellows, residents and medical students.
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Otto Warburg won the Nobel Prize in Physiology and Medicine in 1931 for describing how animal tumors produce large quantities of lactic acid (Wikipedia)
The alkaline tide phenomenon in studies that measured both the alkaline tide and acid secretion, the bicarbonate accumulation increased in linear fashion with the acid secretion. Melanie thought this was first recognized in the 60’s but later found this manuscript from 1939 in JCI! ALKALINE TIDES - PMC
JC mentioned that the anion gap does change in cirrhosis when the albumin is very low but using the correction factor may not change the clinical findings
Chapter Eighteen: Metabolic Alkalosis, part 1
Season 1 · Episode 26
Sunday, March 23, 2025 • Duration 01:05:53
We are a bit slappy at the beginning of the episode since we had just recorded our conversation with the Glaucomfleckens.
On the mechanism by which chloride corrects metabolic alkalosis in man and this is the study when they induced a metabolic alkalosis and studied the effect of treating with KCl vs NaPhos and found the former (with chloride) reversed the alkalosis but not the sodium containing protocol.
Some elegant reports on the increased proximal reabsorption of bicarbonate above normal stimulated by Ang II.
Lety referenced the Cr x 20 formula, a strategy to multiply the serum creatinine by 20 to estimate the initial furosemide dose. We agreed that this is more appropriate than the House of God formula of age + BUN = dose (which may be so much higher).
We referred to David Goldfarb’s teaching on kidney stones in patients with acidification defects: A Woman with Recurrent Calcium Phosphate Kidney Stones (we also referenced this in an earlier episode but this one is a fan favorite).
Diagnostic Importance of an Increased Serum Anion Gap | NEJM Melanie mentioned the work of Patricia Gabow on the anion gap. In this review, she refers to work that she had done to try to identify all the organic anions in the anion gap but it falls short.
But differential includes primary renal Na retention and ARDS
Wedge pressure will exceed 18-20 mmHg with heart or primary Na retention, but is relatively normal with ARDS
Uncomplicated cirrhosis does not cause pulmonary edema
Increased capillary pressure in this disorder is only seen below the hepatic vein
Normal or reduced blood volume in the cardiopulmonary circulation
Peripheral edema and ascites
Peripheral edema is cosmetically undesireable but produces less serious symptoms
Symptoms: swollen legs, difficulty walking, increased abdominal girth, shortness of breath due to pressure on the diaphragm.
Pitting edema found in dependent areas
Ascites found in abdomen
Nephrotic syndrome low tissue pressure areas like eye orbits
Heart Failure (right sided) peripheral edema, abdominal wall, SOB is due to concomitant pulmonary disease. Right sided heart failure increases venous pressure
Cirrhosis develop cirrhosis and lower extremity edema, pressure above the hepatic vein is normal or low.
Tense ascites can increase the pressure above the diaphragm but is relieved with a tap
Portal pressure > 12 mmHg required for fluid retention
Love the case history 16-1
Primary renal sodium retention
Pulmonary and peripheral edema
Jugular venous pressure is elevated
Nephrotic Syndrome
Periorbital and peripheral edema, rarely ascites
CVP normal to high
Idiopathic edema
Behaves as volume depleted (especially with diuretics)
Etiology and treatment
General principles of treatment
When must edema be treated
What are the consequences of the removal of fluid
How rapidly should fluid be removed
When
Pulmonary edema is the only form of generalized edema that is life threatening and demands immediate treatment
Important for note: laryngeal edema and angioedema. Cerebral edema
What are the consequences
If the edema fluid is compensatory (heart failure, cirrhosis, capillary leak syndromes) then removal of fluid with diuretics will diminish effective circulating volume.
Despite this drop in effective circulating volume, most patients benefit from the appropriate use of diuretics.
Cardiac output falls 20% with diuresis of pulmonary congestion but exercise tolerance increases
Says to be careful in diuresis leads to increases in Cr
How rapidly should edema fluid be removed
Removing vascular fluid changes starling forces (reduced venous pressure) so fluid rapidly mobilized from interstitium. 2-3 liters per 24 hours can often be removed without difficulty
An exception is cirrhosis and ascites without peripheral edema. Mobilizing ascites is limited to 500-750 ml/day
Heart failure
Edema is due to increase in venous pressure raising capillary hydrostatic pressure
Ischemic and hypertensive CM impairs left ventricular function causing pulmonary but little peripheral edema
In acute pulmonary edema the LV disease results in increased LVEDP and increased left atrial pressure which transmit back to the pulmonary vein
When wedge exceeds 18-20 (normal is 5-12) get pulmonary edema
Cor pulmonale due to pure right heart failure prominent edema in the lower extremities
Cardiomyopathies tend to affect right and left ventricles leading to simultaneous onset of pulmonary and peripheral edema.
Discusses forward hypothesis in which reduction in cardiac output triggers decreased tissue perfusion activation of SNS and RAAS.
Catecholamines increase cardiac output
RAAS increase Sodium retention
Edema is absent and patients can be compensated at the expense of increased LVEDP see Figure 16-6
Figure 16-6 A to B to C with compensation
Eventually the increased sodium retention and increased intracranial pressure are enough to cause edema.
He then brings up multiple important points (in bullets none the less)
Dual effects of fluid retention:
Increased cardiac output
Potential harmful elevation in venous pressure
Benefit is found with increase in LVEDP from 12 to 15, after that it seems mostly deleterious
Vascular congestion (elevated LVEDP) and a low cardiac output do not have to occur together. See points B and C on 16-6.
Frank-Starling relationship varies with exercise.
Patients with moderate heart disease may be okay at rest but fail with mild exertion. This leads to more neurohormonal activation. This can worsen sodium retention and ischemia. Rest here can help augment diuretic effect. Doubling diuretic response. 40% increase in GFR.
Mild to mod heart disease may have no edema with dietary Na restriction. Na intake will initially increase preload and improve cardiac output and allow the Na to be excreted but as the Frank Starling curves flatten then excess sodium cannot be excreted.
Diastolic vs Systolic dysfunction
Decreased compliance in diastolic dysfunction can lead to flash pulmonary edema
More common with hypertension
Look to the ejection fraction
Neurohormonal adaptation
Initial benefit long term adverse effects
Norepi, renin, ADH all are vasoconstrictors
They raise cardiac output
Raise BP which is maladaptive in the long term
Treatment of cardiogenic pulmonary edema
Morphine
Oxygen
Loop diuretic
NTG/nitroprusside
If patient remains in pulmonary edema and has systolic dysfunction consider inotropic agent
Treatment of chronic heart failure
Feels dated
Mentions dig and loop diuretic
But also ACEi/BB and AA
Deep dive
Loop diuretics
ACEi
Cor Polminale
Edema here comes with increased CO2
Associated with increased HCO3 which means increased
HCO3 reabsorption int he proximal tubule which leads to more sodium retention
Hypoxemia can increase Na retention
Cirrhosis and Ascites
Both lymphatic obstruction and increased capillary permeability contribute
Sinusoidal obstruction leads to increased hydraulic pressure in the sinusoids.
Portal hypertension is necessary for ascites
> 12 mmHg
The low albumin is often present but is not contributory to edema
Sinusoids are freely permeable to albumin so no oncotic pressure from albumin here
Mechanism of ascites
Renal sodium conservation is an early finding and some evidence for primary sodium retention but…
Mostly underfill is thought to drive Na retention
Splanchnic vasodilation starts this of
NO drives this
Endotoxin absorption stimulates No
Normally endotoxin is detoxed in liver but portosystemic shunting allows endotoxin to escape the liver.
Hepatorenal syndrome
Progressive hemodynamically mediated fall in GFR
Induced by intense renal vasocontstriction
Where are the PGE and Kinins
Fall in GFR is masked by decreased muscle mass and decreased BUN production
Hyponatremia is a grave prognostic sign, as it is in heart failure, Indicates increased activation of vasopressin
Treatment
Low Na intake
Low water intake
Care with diuretics, can only mobilize 300-500 ml of ascetic fluid a day
Avoid hypokalemia
Stimulates NH3 production
Talks about the mechanism in proximal tubule
Also discusses pKA of NH3->NH4 reaction and if the pH rises, this will shift the Eq to produce NH3
Important aspect in NH3 is lipid soluble and NH is not
Says that Spiro is diuretic of choice
States it is more effective than furosemide in this condition
Effectiveness related to slower rate of drug excretionin urine (compromises furosemide but not spiro) competition with bile salts
Recommends 40 furosemide and 100 of spiro
Resistant ascites
Options
paracentesis
TIPS
Complicated by higher mortality
Peritoneovenous shunt
Largely abandoned,
Primary renal sodium retention
CKD or AKI where low GFR linits excretion of Water and Na
Acute GN or nephrotic syndrome
Broken glom with intact tubules, mean the tubules see less Na so they think “underperfused” and then they increase renal retention of NA
Drugs
Direct vasodilators like minoxidil
Require super high furosemide doses to counter
Other antihypertensives either block sympathetic NS, Na retention directly or block RAAS explains why they don’t cause Na retention
NSAIDS
Fludrocortisone
Pregnancy
Normal pregnancy is associated with retention of 900 to 1000 mEq of Na
Lp is the unit permeability or porosity of the capillary wall. S is the surface area.
Sigma is the reflection coefficient ranging from zero for completely permeable to 1 for for impermeable
Difficult to measure these values in humans and animals
16-1 is a table of starling force values. No reflection coefficient though
Figure 16-2 shows values in subcutaneous tissues. PCap 17.3 Oncotic pressure in cap is 28. Says mean net gradient is 0.3 mmHg favoring filtration out of the vascular space. This excess net is returned to the systemic circulation by lymphatics.
In the liver the values are different.
The hepatic sinusoids are highly permeable to protein so oncotic pressure is neutralized by zero reflection coefficient. SO hydraulic pressure favoring filtration is unopposed.
Cap hydraulic pressure is lower since two thirds of hepatic blood flow is from low pressure portal vein.
Still large pressure gradient favoring filtration
Alveolar capillaries are similar to the liver Low cap hydraulic pressure, more permeable to proteins so no transcapillary oncotic pressure.
Edema formation requires alteration of one or more starling forces to favor net filtration
Increased capillary hydraulic pressure would do it
Increased interstitial oncotic pressure too
Reduction in plasma oncotic pressure
Lymphatic obstruction too
Increased capillary hydraulic pressure
Capillary hydraulic pressure is insensitive to alteration in arterial pressure due to autoregulation in the pre-capillary sphincter
Constricts in response to increases in arterial pressure
No sphincter at venous end, so changes in venous pressure are transmitted to capillary bed.
Blood volume expanded increases pressure in enough system
Heart failure
Renal disease
Venous obstruction
Cirrhosis
DVT
Decreased plasma oncotic pressure
Hypo albuminuria
May be less common than previously suspected
Increased capillary permeability
Promotes edema directly and by permitting albumin to move into interstitium, decreasing the oncotic pressure gradient
Burns both histamine and oxygen free radicals cause microvascular injury
Therapy with IL-2 increases capillary permeability
Episodic idiopathic capillary leak syndromes by IL-2 receptors on mononuclear cells or increased generations of kinins.
Patients often with monoclonal gammopathy and during episodes have a massive leak of proteins and fluids, hematocrit rises 70-80%.
Aminophylline and terbutaline may prevent. episodes
ARDS
Ischemia or sepsis induced release of cytokines such as IL-1, IL-8 or TNF may have role in creasing pulmonary capillary permeability
DM also increases capillary permeability and may have a role in the edema which is primarily generated by other factors, heart failure or NS
Lymphatic obstruction
Most often with nodal enlargement due to malignancy
Called lymphedema
Hypothyroidism marked increase in interstitial accumulation of albumin and other proteins.
Low lymphatic flow in hypothyroidema, myxedema.
Resistant to diuretics which will put patient at risk of hypovolemia.
Safety factors
Needs to be 15 mmHg increase in the gradient favoring filtration before edema is seen
Three factors explain this protective response
Increased lymphatic flow can remove excess filtrate
Fluid entry into interstitium lowers the oncotic pressure by dilution and lymphatic mediated removal of proteins
Increased fluid entry to interstitium increases interstitial hydraulic pressure
Talks about hypoalbuminemia and edema
This is a lot of underfill vs overfill theory.
Nice bullet points at bottom of 487 how heterogeneity of etiology of edema with MCD.
Talks about pulmonary edema and how high interstitial protein provides large safety factor, interstitial albumin has a long way to fall to prevent pulmonary edema.
Mentions kwashiorkor and how it may not be low albumin that causes this.
Renal sodium retention
Can be due to primary renal disease causing sodium retention
NS, GN
More commonly is renal salt retention is an appropriate compensatory response to decreased effective circulating volume
States that decreased effective circulating volume can become compensated and renin falls back to normal.
Had interesting figure 16-5 “The Compensated State”
Symptoms and diagnosis
Three factors important in the mechanism of edema
The pattern of distribution of edema which reflects those capillaries with altered hemodynamic forces
But differential includes primary renal Na retention and ARDS
Wedge pressure will exceed 18-20 mmHg with heart or primary Na retention, but is relatively normal with ARDS
Uncomplicated cirrhosis does not cause pulmonary edema
Increased capillary pressure in this disorder is only seen below the hepatic vein
Normal or reduced blood volume in the cardiopulmonary circulation
Peripheral edema and ascites
Peripheral edema is cosmetically undesireable but produces less serious symptoms
Symptoms: swollen legs, difficulty walking, increased abdominal girth, shortness of breath due to pressure on the diaphragm.
Pitting edema found in dependent areas
Ascites found in abdomen
Nephrotic syndrome low tissue pressure areas like eye orbits
Heart Failure (right sided) peripheral edema, abdominal wall, SOB is due to concomitant pulmonary disease. Right sided heart failure increases venous pressure
Cirrhosis develop cirrhosis and lower extremity edema, pressure above the hepatic vein is normal or low.
Tense ascites can increase the pressure above the diaphragm but is relieved with a tap
Portal pressure > 12 mmHg required for fluid retention
Love the case history 16-1
Primary renal sodium retention
Pulmonary and peripheral edema
Jugular venous pressure is elevated
Nephrotic Syndrome
Periorbital and peripheral edema, rarely ascites
CVP normal to high
Idiopathic edema
Behaves as volume depleted (especially with diuretics)
Etiology and treatment
General principles of treatment
When must edema be treated
What are the consequences of the removal of fluid
How rapidly should fluid be removed
When
Pulmonary edema is the only form of generalized edema that is life threatening and demands immediate treatment
Important for note: laryngeal edema and angioedema. Cerebral edema
What are the consequences
If the edema fluid is compensatory (heart failure, cirrhosis, capillary leak syndromes) then removal of fluid with diuretics will diminish effective circulating volume.
Despite this drop in effective circulating volume, most patients benefit from the appropriate use of diuretics.
Cardiac output falls 20% with diuresis of pulmonary congestion but exercise tolerance increases
Says to be careful in diuresis leads to increases in Cr
How rapidly should edema fluid be removed
Removing vascular fluid changes starling forces (reduced venous pressure) so fluid rapidly mobilized from interstitium. 2-3 liters per 24 hours can often be removed without difficulty
An exception is cirrhosis and ascites without peripheral edema. Mobilizing ascites is limited to 500-750 ml/day
Heart failure
Edema is due to increase in venous pressure raising capillary hydrostatic pressure
Ischemic and hypertensive CM impairs left ventricular function causing pulmonary but little peripheral edema
In acute pulmonary edema the LV disease results in increased LVEDP and increased left atrial pressure which transmit back to the pulmonary vein
When wedge exceeds 18-20 (normal is 5-12) get pulmonary edema
Cor pulmonale due to pure right heart failure prominent edema in the lower extremities
Cardiomyopathies tend to affect right and left ventricles leading to simultaneous onset of pulmonary and peripheral edema.
Discusses forward hypothesis in which reduction in cardiac output triggers decreased tissue perfusion activation of SNS and RAAS.
Catecholamines increase cardiac output
RAAS increase Sodium retention
Edema is absent and patients can be compensated at the expense of increased LVEDP see Figure 16-6
Figure 16-6 A to B to C with compensation
Eventually the increased sodium retention and increased intracranial pressure are enough to cause edema.
He then brings up multiple important points (in bullets none the less)
Dual effects of fluid retention:
Increased cardiac output
Potential harmful elevation in venous pressure
Benefit is found with increase in LVEDP from 12 to 15, after that it seems mostly deleterious
Vascular congestion (elevated LVEDP) and a low cardiac output do not have to occur together. See points B and C on 16-6.
Frank-Starling relationship varies with exercise.
Patients with moderate heart disease may be okay at rest but fail with mild exertion. This leads to more neurohormonal activation. This can worsen sodium retention and ischemia. Rest here can help augment diuretic effect. Doubling diuretic response. 40% increase in GFR.
Mild to mod heart disease may have no edema with dietary Na restriction. Na intake will initially increase preload and improve cardiac output and allow the Na to be excreted but as the Frank Starling curves flatten then excess sodium cannot be excreted.
Diastolic vs Systolic dysfunction
Decreased compliance in diastolic dysfunction can lead to flash pulmonary edema
More common with hypertension
Look to the ejection fraction
Neurohormonal adaptation
Initial benefit long term adverse effects
Norepi, renin, ADH all are vasoconstrictors
They raise cardiac output
Raise BP which is maladaptive in the long term
Treatment of cardiogenic pulmonary edema
Morphine
Oxygen
Loop diuretic
NTG/nitroprusside
If patient remains in pulmonary edema and has systolic dysfunction consider inotropic agent
Treatment of chronic heart failure
Feels dated
Mentions dig and loop diuretic
But also ACEi/BB and AA
Deep dive
Loop diuretics
ACEi
Cor Polminale
Edema here comes with increased CO2
Associated with increased HCO3 which means increased
HCO3 reabsorption int he proximal tubule which leads to more sodium retention
Hypoxemia can increase Na retention
Cirrhosis and Ascites
Both lymphatic obstruction and increased capillary permeability contribute
Sinusoidal obstruction leads to increased hydraulic pressure in the sinusoids.
Portal hypertension is necessary for ascites
> 12 mmHg
The low albumin is often present but is not contributory to edema
Sinusoids are freely permeable to albumin so no oncotic pressure from albumin here
Mechanism of ascites
Renal sodium conservation is an early finding and some evidence for primary sodium retention but…
Mostly underfill is thought to drive Na retention
Splanchnic vasodilation starts this of
NO drives this
Endotoxin absorption stimulates No
Normally endotoxin is detoxed in liver but portosystemic shunting allows endotoxin to escape the liver.
Hepatorenal syndrome
Progressive hemodynamically mediated fall in GFR
Induced by intense renal vasocontstriction
Where are the PGE and Kinins
Fall in GFR is masked by decreased muscle mass and decreased BUN production
Hyponatremia is a grave prognostic sign, as it is in heart failure, Indicates increased activation of vasopressin
Treatment
Low Na intake
Low water intake
Care with diuretics, can only mobilize 300-500 ml of ascetic fluid a day
Avoid hypokalemia
Stimulates NH3 production
Talks about the mechanism in proximal tubule
Also discusses pKA of NH3->NH4 reaction and if the pH rises, this will shift the Eq to produce NH3
Important aspect in NH3 is lipid soluble and NH is not
Says that Spiro is diuretic of choice
States it is more effective than furosemide in this condition
Effectiveness related to slower rate of drug excretionin urine (compromises furosemide but not spiro) competition with bile salts
Recommends 40 furosemide and 100 of spiro
Resistant ascites
Options
paracentesis
TIPS
Complicated by higher mortality
Peritoneovenous shunt
Largely abandoned,
Primary renal sodium retention
CKD or AKI where low GFR linits excretion of Water and Na
Acute GN or nephrotic syndrome
Broken glom with intact tubules, mean the tubules see less Na so they think “underperfused” and then they increase renal retention of NA
Drugs
Direct vasodilators like minoxidil
Require super high furosemide doses to counter
Other antihypertensives either block sympathetic NS, Na retention directly or block RAAS explains why they don’t cause Na retention
NSAIDS
Fludrocortisone
Pregnancy
Normal pregnancy is associated with retention of 900 to 1000 mEq of Na
JC”s abstract on use of loop diuretics in hepatorenal syndrome type 1 was ultimately published in the American Journal of the Medical Sciences: https://doi.org/10.1016/S0002-9629(23)00623-7
- Presence of counterbalancing antinatriuretic forces
- Ang2
- Aldo
- Low systemic BP
- Adds rate of drug excretion as # 2 and a half
- Almost all diuretics are protein bound
- So not well filtered
- Enter tubule through organic anion and organic cation transporter
- This can limit diuretic effectiveness
- Natriuretic response plateaus at higher rates of diuretic excretion due to complete inhibition of the diuretic target
- This plateau in normal people is 1 mg of bumetanide and 40 mg of furosemide given IV
- Double this for oral furosemide, no adjustment needed for bumetanide
- 15-6
- Refractory edema
- Start with a loop diuretic
- Initial aim is to find the effective single dose
- From the paragraph this is about threshold dosing
- Double ineffective doses until good effect
- Suggests maximum furosemide dose is 200 mg IV and 400 mg oral
- Excess sodium intake
- High sodium diet can work to prevent patients from achieving negative sodium balance.
- Suggests diets after leaving the hospital maybe higher in sodium
- Decreased or delayed intestinal absorption
- Decreased intestinal perfusion, reduced intestinal motility and mucosal edema may contribute.
- But why is this worse with furosemide than with bumetidine or torsemide?
- Decreased drug entry into the tubular lumen
- Thiazides don’t work below a GFR of 20
- CLICK
- Renal failure
- Increased organic anions compete for diuretic secretion
- Bumetidine isn’t as dependent as furosemide on GFR
- Use 1/20th rather than 1/40th the dose
- Maximum of 8 to 10 mg
- Furosemide has ototoxicirty at high doses, he advises against 2400 mg/day
- There is a Na-K-2Cl carrier in the endolymph producing cells
- Ethacrynic acid has the most ototoxicity
- Only loop or thiazide that isn’t a sulfonamide derivative
- Cirrhosis
- Spiro is diuretic of choice
- More effective than loops alone
- Does not induce hypokalemia that can cause hepatic encephalopathy
- Cirrhosis causes marked hyperaldo
- Loop diuretics have to compete with bile salts for secretion in the proximal tubule
- Spiro does not need to be secreted in the proximal tubule
- Recommends to 100 to 40 spiro to furosemide ratio
- And can double this to 200 and 80/day
- and a maximum of of 400/160
- Hypoalbuminemia
- <2 g/dL associated with decreased diuretic entry into the lumen
- Protein binding keeps diuretics in the blood, reduces the volume of distribution
- This maximizes the delivery to the kidney
- In nephrotic syndrome tubular albumin can bind diuretic and prevent its activity
- Co administration of albumin with diuretic has resulted in modest improvements in diuretic effectiveness in various studies
- Intravenous infusion of loop diuretics
- Infusions are greater than bolus
- But if patient is not responding to blouses unlikely to respond to infusions since bolus provides a temporary spike in plasma level
- Increased distal reabsorption
- Increased distal sodium reabsorption decreases the effectiveness of proximal diuretics
- Due to aldo and increased sodium delivery
- Mentions that thiazides have a proximal effect (is that inhibition of carbonic anhydrase?)
- 15-8 is very cool
- Says all thiazides are created equal
- Article from 1972 is why people use metolazone in advanced renal disease
- When doing sequential nephron blocked be careful
- Loss of lots of fluid
- Loss of lots of potassium
- Loss of 5 liters and 200 mEq of K a day is possible with sequential nephron blockade
- Decreased loop sodium delivery
- With heart failure and cirrhosis increased proximal resorption mediated by Ang II markedly reduces delivery of fluid to the diuretic sensitive sites.
- Acetazolamide makes sense here
- Supine or 10 degree head down can increase cardiac output possibly increased venous return
- Can double Na excretion
- Increase CrCl 40%
- CAVH enters the chat!
- Other uses of diuretics
- Met alk, RTA, DI, hyponatremia due to SIADH, hypokalemia
- Diuretics and prostaglandins
- Loops and thiazides increase renal generation of prostaglandins
- Can cause venous dilation may help with acute pulmonary edema
- Can help without increased diuresis
- NSAIDS counter the effect of loop diuretics
- Is this natriuretic effect of PGE? Or due to renal ischemia due to unopposed Ang2 and norepi
- They also raise BP and reduce cardiac output due to increased vascular resistance
- Vasoconstrictor effect of loop diuretics
- One hour after loop diuretics increase vasoconstriction and rise in systemic blood pressure
- Increased Renin and norepinephrine, resolved 4 hours later
- Seen in heart failure and cirrhosis
- In cirrhosis decrease in RPF and GFR of 30-40% with furosemide
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