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A positive urinary anion gap (when the sum of Na+ plus K+ is greater than Cl-) implies impaired renal acid secretion aka absence of ammonium.
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Urine anions aka negative charges = chloride Cl –Ī negative (“neg-GUT-ive”) anion gap implies the presence of ammonium (NH4+), which means renal acid secretion remains intact. Urine cations aka positive charges = sodium Na +, potassium K +, ammonium NH4 + (Urine Na + + K + ) – Urine Cl – = Urine anion gap Sodium bicarbonate 325 mg tab = 4 mmol bicarbonateīaking soda, one teaspoon = 60 mmol bicarbonate
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Sodium bicarbonate 650 mg tab = 8 mmol bicarbonate Split non-gap metabolic acidosis into three buckets (see figure below): A positive gap in setting of metabolic acidosis suggests an RTA.Īll figures included created by Joel Topf MD and reproduced with his permission. Remember: a “neg-GUT-ive” gap means ammonium is present and effective renal acid secretion is intact. Urine anion gap: Indirectly measures ammonium (NH4+).One teaspoon of baking soda has 60 mmol bicarb Bicarbonate pills come in 650 mg (8 mmol bicarb) or 325 mg (4 mmol bicarb). Note: 1 mEq/L = 1 mmol/L for bicarbonate. Bicarbonate repletion: Treat to serum bicarb > 22.Type 4 RTA (hypoaldosteronism): Chronic hyperkalemia impairs ammoniagenesis.Treatment: Bicarbonate +/- potassium replacement Complications: Hypo- or hyperkalemia (depending on defect) Osteoporosis Nephrolithiasis (worse on treatment). Distal Type 1 RTA: Failure of H+ secretion in distal nephron with multiple mechanisms.Complications: Osteoporosis Nephrolithiasis and hypokalemia occur if bicarbonate (alkali) therapy given due to bicarbonaturia. Serum bicarbonate drops to new “set point”. Proximal renal tubular acidosis (Type 2 RTA): Damage to proximal tubule impairs bicarbonate reabsorption.Using “balanced” solution like ringer’s lactate instead of saline reduced major adverse kidney events by 1% in the SMART and SALTED trials NEJM 2018. Normal saline creates a non anion gap metabolic acidosis (NAGMA) due to chloride 154 mEq/L.Non gap metabolic acidosis: GI losses are the most common cause so “don’t go looking for the zebra of RTA”.Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Written by: Matthew Watto MD and Joel Topf MD Rate us on iTunes, recommend a guest or topic and give feedback at.
RTA 1 PDF
Join our mailing list and receive a PDF copy of our show notes every Monday. You may want to go back and check out episode #88 Acid Base, Boy Bands and Grandfather Clocks with Joel Topf MD if you haven’t heard it yet. Check out Dr Topf’s awesome slides on renal tubular acidosis at. We review the three buckets of non gap metabolic acidosis, normal renal physiology & acid base handling, points of failure in RTA, complications and treatment of RTA. Renal tubular acidosis aka RTA deconstructed by Joel Topf MD, Chief of Nephrology at Kashlak Memorial Hospital.