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Metabolic Alkalosis

Metabolic alkalosis is primary increase in HCO3 with or without compensatory increase in Pco2; pH may be high or nearly normal. Common causes include prolonged vomiting, hypovolemia, diuretic use, and hypokalemia. Renal impairment of HCO3 excretion must be present to sustain alkalosis. Symptoms and signs in severe cases include headache, lethargy, and tetany. Diagnosis is clinical and with ABG and serum electrolyte measurement. The underlying cause is treated; oral or IV acetazolamide or HCl is sometimes indicated.

Etiology

Metabolic alkalosis is HCO3 accumulation due to acid loss, alkali administration, intracellular shift of hydrogen ion (H+—as occurs in hypokalemia), or HCO3 retention. Regardless of initial cause, persistence of metabolic alkalosis indicates that the kidneys have increased their HCO3 reabsorption, because HCO3 is normally freely filtered by the kidneys and hence excreted. Volume depletion and hypokalemia are the most common stimuli for increased HCO3 reabsorption, but any condition that elevates aldosterone or mineralocorticoids (which enhance Na reabsorption and K and H+ excretion) can elevate HCO3. Thus, hypokalemia is both a cause and a frequent consequence of metabolic alkalosis. Causes are listed; the most common are volume depletion (particularly when involving loss of gastric acid and Cl from recurrent vomiting or nasogastric suction) and diuretic use (Table 4: Acid-Base Regulation and Disorders: Causes of Metabolic AlkalosisTables).

Table 4

Causes of Metabolic Alkalosis

Cause

Comments

GI acid loss*

Gastric acid loss due to vomiting or nasogastric suction

Loss of HCl and acid coupled with contraction alkalosis due to release of aldosterone and subsequent resorption of HCO3

Congenital chloridorrhea

Fecal Cl loss and HCO3 retention

Villous adenoma

Probably secondary to K depletion

Renal acid loss

Primary hyperaldosteronism

Includes congenital adrenal hyperplasia

Secondary hyperaldosteronism

Occurs with volume depletion, heart failure, cirrhosis with ascites, nephrotic syndrome, Cushing's syndrome or disease, renal artery stenosis, or renin-secreting tumor

Use of glycyrrhizin-containing compounds (eg, licorice, chewing tobacco, carbenoxolone, Lydia Pinkham's vegetable compound)

Glycyrrhizin inhibition of enzymatic conversion of cortisol to less active metabolites

Bartter syndrome

Rare congenital disease causing hyperaldosteronism and hypokalemic metabolic alkalosis that manifests in early childhood with renal salt wasting and volume depletion

Gitelman's syndrome

Similar to Bartter syndrome; characterized in addition by hypomagnesemia and hypocalciuria; manifests in young adults

Diuretics (thiazide and loop)

Multiple mechanisms: Secondary hyperaldosteronism due to volume depletion, Cl depletion, or contraction alkalosis; may be Cl-unresponsive because of concomitant K depletion

Hypokalemia and hypomagnesemia

Stimulate K and Mg reabsorption and H excretion; alkalosis unresponsive to NaCl and volume replacement until deficiencies corrected; low K causing H to shift into cells and raising extracellular pH

HCO3 excess

Posthypercapnic*

Persistent elevation of compensatory HCO3 levels, often with volume, K, and Cl depletion

Postorganic acidosis

Conversion of lactic acid or ketoacid to HCO3 worsened by HCO3 therapy for acidosis

NaHCO3 loading

Occurs with overzealous loading or with loading in patients who have hypokalemia; as H shifts back into cells, serum becomes more alkalotic

Milk-alkali syndrome

Chronic ingestion of Ca carbonate antacids provides Ca and HCO3 load; hypercalcemia decreases and GFR prevents elimination of the excess HCO3 load

Contraction alkalosis*

Diuretics (all types)

Sweat loss in cystic fibrosis

NaCl loss concentrates a fixed amount of HCO3 in a smaller total body volume

Other

Carbohydrate refeeding after starvation

Resolution of starvation ketosis or acidosis with improved cellular function

Laxative abuse*

Unclear mechanism

Some antibiotics (carbenicillinSome Trade Names
GEOCILLIN

, penicillin, ticarcillinSome Trade Names
TICAR

)

Contain nonreabsorbable anion, which increases K and H excretion

*Cl-responsive.

Cl-unresponsive.

May be either Cl-responsive or Cl-unresponsive.

Metabolic alkalosis involving loss or excess secretion of Cl is termed Cl-responsive, because it typically corrects with IV administration of NaCl-containing fluid. Cl-unresponsive metabolic alkalosis does not, and it typically involves severe Mg or K deficiency or mineralocorticoid excess. The 2 forms can coexist, eg, in patients with volume overload made hypokalemic from high-dose diuretics.

Symptoms and Signs

Symptoms and signs of mild alkalemia are usually related to the underlying disorder. More severe alkalemia increases protein binding of ionized Ca++, leading to hypocalcemia and subsequent headache, lethargy, and neuromuscular excitability, sometimes with delirium, tetany, and seizures. Alkalemia also lowers threshold for anginal symptoms and arrhythmias. Concomitant hypokalemia may cause weakness.

Diagnosis

  • ABG and serum electrolytes
  • Diagnosis of cause usually clinical
  • Sometimes measurement of urinary Cl and K+

Recognition of metabolic alkalosis and appropriate respiratory compensation is discussed in Acid-Base Regulation and Disorders: Diagnosis and requires ABG and measurement of serum electrolytes (including Ca and Mg).

Common causes can often be determined by history and physical examination. If history is unrevealing and renal function is normal, urinary Cl and K+ concentrations are measured (values are not diagnostic in renal insufficiency). Urinary Cl < 20 mEq/L indicates significant renal Cl reabsorption and hence a Cl-responsive cause (see Table 4: Acid-Base Regulation and Disorders: Causes of Metabolic AlkalosisTables). Urinary Cl > 20 mEq/L suggests a Cl-unresponsive form.

Urinary K and presence or absence of hypertension help differentiate Cl-unresponsive alkaloses. Urinary K < 30 mEq/day signifies hypokalemia or laxative misuse. Urinary K > 30 mEq/day without hypertension suggests diuretic abuse or Bartter or Gitelman's syndrome. Urinary K > 30 mEq/day with hypertension requires evaluation for hyperaldosteronism, mineralocorticoid excess, and renovascular disease. Tests typically include plasma renin activity and aldosterone and cortisol levels (see Adrenal Disorders: Diagnosis and see Adrenal Disorders: Diagnosis).

Treatment

  • Cause treated
  • IV 0.9% saline solution for Cl-responsive metabolic alkalosis

Underlying conditions are treated, with particular attention paid to correction of hypovolemia and hypokalemia.

Patients with Cl-responsive metabolic alkalosis are given 0.9% saline solution IV; infusion rate is typically 50 to 100 mL/h greater than urinary and other sensible and insensible fluid losses until urinary Cl rises to > 25 mEq/L and urinary pH normalizes after an initial rise from bicarbonaturia. Patients with Cl-unresponsive metabolic alkalosis rarely benefit from rehydration alone.

Patients with severe metabolic alkalosis (eg, pH > 7.6) sometimes require more urgent correction of serum pH. Hemofiltration or hemodialysis is an option, particularly if volume overload and renal dysfunction are present. AcetazolamideSome Trade Names
DIAMOX
Click for Drug Monograph
250 to 375 mg po or IV once/day or bid increases HCO3 excretion but may also accelerate urinary losses of K+ and phosphate (PO4); volume-overloaded patients with diuretic-induced metabolic alkalosis and those with posthypercapnic metabolic alkalosis may especially benefit.

Hydrochloric acid in a 0.1 to 0.2 normal solution IV is safe and effective but must be given through a central catheter because it is hyperosmotic and scleroses peripheral veins. Dosage is 0.1 to 0.2 mmol/kg/h. Frequent monitoring of ABG and electrolytes is needed.

Last full review/revision July 2008 by James L. Lewis, III, MD

Content last modified July 2008

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