Treatment of metabolic alkalosis
- Ankit Mehta, MD
Ankit Mehta, MD
- Assistant Professor, Department of Internal Medicine, Texas A&M College of Medicine, Dallas
- Associate Program Director, Internal Medicine Residency, Baylor University Medical Center, Dallas
- Michael Emmett, MD
Michael Emmett, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Chief of Internal Medicine
- Baylor University Medical Center
Metabolic alkalosis is characterized by a primary rise in the plasma bicarbonate concentration, which leads to an increase in arterial pH. Two factors are required for the genesis and then maintenance of metabolic alkalosis: a process that raises the plasma bicarbonate concentration and a process that prevents excretion of the excess bicarbonate in the urine [1,2]. Treatment of metabolic alkalosis should be aimed at reversing these two factors.
This topic will provide a brief overview of the pathogenesis of metabolic alkalosis followed by a discussion of how to treat affected patients. The pathogenesis of metabolic alkalosis is reviewed in more detail elsewhere. (See "Pathogenesis of metabolic alkalosis".)
The etiology and evaluation of patients with metabolic alkalosis are discussed separately. (See "Causes of metabolic alkalosis" and "Clinical manifestations and evaluation of metabolic alkalosis".)
OVERVIEW OF THE PATHOGENESIS
The genesis and the maintenance of metabolic alkalosis are distinct processes. Initially, a process that raises the plasma bicarbonate concentration occurs, and then another process prevents excretion of the excess bicarbonate in the urine [1,2].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001. p.552.
- Schwartz WB, Van Ypersele de Strihou, Kassirer JP. Role of anions in metabolic alkalosis and potassium deficiency. N Engl J Med 1968; 279:630.
- VAN GOIDSENHOVEN GM, GRAY OV, PRICE AV, SANDERSON PH. The effect of prolonged administration of large doses of sodium bicarbonate in man. Clin Sci 1954; 13:383.
- Galla JH. Metabolic alkalosis. J Am Soc Nephrol 2000; 11:369.
- Barton CH, Vaziri ND, Ness RL, et al. Cimetidine in the management of metabolic alkalosis induced by nasogastric drainage. Arch Surg 1979; 114:70.
- Kirsch BM, Sunder-Plassmann G, Schwarz C. Metabolic alkalosis in a hemodialysis patient--successful treatment with a proton pump inhibitor. Clin Nephrol 2006; 66:391.
- Luke RG, Galla JH. It is chloride depletion alkalosis, not contraction alkalosis. J Am Soc Nephrol 2012; 23:204.
- Galla JH, Gifford JD, Luke RG, Rome L. Adaptations to chloride-depletion alkalosis. Am J Physiol 1991; 261:R771.
- Verlander JW, Madsen KM, Galla JH, et al. Response of intercalated cells to chloride depletion metabolic alkalosis. Am J Physiol 1992; 262:F309.
- Wagner CA, Devuyst O, Bourgeois S, Mohebbi N. Regulated acid-base transport in the collecting duct. Pflugers Arch 2009; 458:137.
- SCHWARTZ WB, HAYS RM, POLAK A, HAYNIE GD. Effects of chronic hypercapnia on electrolyte and acid-base equilibrium. II. Recovery, with special reference to the influence of chloride intake. J Clin Invest 1961; 40:1238.
- Wall BM, Byrum GV, Galla JH, Luke RG. Importance of chloride for the correction of chronic metabolic alkalosis in the rat. Am J Physiol 1987; 253:F1031.
- Tannen RL, Bleich HL, Schwartz WB. The renal response to acid loads in metabolic alkalosis; an assessment of the mechanisms regulating acid excretion. J Clin Invest 1966; 45:562.
- COOKE RE, SEGAR WE, CHEEK DB, et al. The extrarenal correction of alkalosis associated with potassium deficiency. J Clin Invest 1952; 31:798.
- Eiam-Ong S, Kurtzman NA, Sabatini S. Regulation of collecting tubule adenosine triphosphatases by aldosterone and potassium. J Clin Invest 1993; 91:2385.
- Capasso G, Jaeger P, Giebisch G, et al. Renal bicarbonate reabsorption in the rat. II. Distal tubule load dependence and effect of hypokalemia. J Clin Invest 1987; 80:409.
- Bear R, Goldstein M, Phillipson E, et al. Effect of metabolic alkalosis on respiratory function in patients with chronic obstructive lung disease. Can Med Assoc J 1977; 117:900.
- Miller PD, Berns AS. Acute metabolic alkalosis perpetuating hypercarbia. A role for acetazolamide in chronic obstructive pulmonary disease. JAMA 1977; 238:2400.
- Banga A, Khilnani GC. Post-hypercapnic alkalosis is associated with ventilator dependence and increased ICU stay. COPD 2009; 6:437.
- Faisy C, Mokline A, Sanchez O, et al. Effectiveness of acetazolamide for reversal of metabolic alkalosis in weaning COPD patients from mechanical ventilation. Intensive Care Med 2010; 36:859.
- Taki K, Mizuno K, Takahashi N, Wakusawa R. Disturbance of CO2 elimination in the lungs by carbonic anhydrase inhibition. Jpn J Physiol 1986; 36:523.
- Brimioulle S, Berre J, Dufaye P, et al. Hydrochloric acid infusion for treatment of metabolic alkalosis associated with respiratory acidosis. Crit Care Med 1989; 17:232.
- Lisawat P, Gennari FJ. Approach to the hemodialysis patient with an abnormal serum bicarbonate concentration. Am J Kidney Dis 2014; 64:151.
- Huber L, Gennari FJ. Severe metabolic alkalosis in a hemodialysis patient. Am J Kidney Dis 2011; 58:144.
- Fall P, Szerlip HM. Continuous renal replacement therapy: cause and treatment of electrolyte complications. Semin Dial 2010; 23:581.
- Morabito S, Pistolesi V, Tritapepe L, et al. Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid-base status and phosphate supplementation needs. BMC Nephrol 2013; 14:232.
- Frick PG, Senning A. The treatment of severe metabolic alkalosis with intravenous N /10 or N /5 hydrochloric acid. Germ Med Monthly 1964; 9:242
- Wagner CW, Nesbit RR Jr, Mansberger AR Jr. Treatment of metabolic alkalosis with intravenous hydrochloric acid. South Med J 1979; 72:1241.
- Kwun KB, Boucherit T, Wong J, et al. Treatment of metabolic alkalosis with intravenous infusion of concentrated hydrochloric acid. Am J Surg 1983; 146:328.
- Buchanan IB, Campbell BT, Peck MD, Cairns BA. Chest wall necrosis and death secondary to hydrochloric acid infusion for metabolic alkalosis. South Med J 2005; 98:822.
- Knutsen OH. New method for administration of hydrochloric acid in metabolic alkalosis. Lancet 1983; 1:953.
- Martin WJ, Matzke GR. Treating severe metabolic alkalosis. Clin Pharm 1982; 1:42.
- Warren SE, Swerdlin AR, Steinberg SM. Treatment of alkalosis with ammonium chloride: a case report. Clin Pharmacol Ther 1979; 25:624.
- Bushinsky DA, Gennari FJ. Life-threatening hyperkalemia induced by arginine. Ann Intern Med 1978; 89:632.
- OVERVIEW OF THE PATHOGENESIS
- Factors that increase plasma bicarbonate
- Factors that impair bicarbonate excretion
- Treat the underlying cause
- Increase renal bicarbonate excretion
- - Reduced arterial or effective arterial blood volume and chloride depletion
- True volume depletion
- Edematous states
- Chloride depletion
- - Potassium depletion
- Treatment of posthypercapnic metabolic alkalosis
- Treatment of metabolic alkalosis with acute or chronic kidney disease
- Hydrochloric acid in selected patients
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS