Acid – Base Balance

By
Dr.P.J.Samuel,
Professor and Head, Dept. of Physiology

Dr.P.J.Samuel
 At the end of this class u must know
• Introduction to Acid and Base
• Introduction to pH
• Source of imbalance
• Mechanisms to balance H+ ion concentration
• Renal Acid Base Regulation
• Anion Gap
• Acid Base Disorders
Dr.P.J.Samuel
Introduction to Acid and Base

Dr.P.J.Samuel
 Introduction to Acids and Bases
• Acid - Release H+ ions …proton donor
– HCl (strong acid) H+ + Cl- (weak base)
– HCN (weak acid) H+ + CN- (strong base)

• Base - Accept H+ ions …proton acceptor

– NaOH (strong base) → Na + + OH - …hydroxyl accepts H +
– HCO3 - (weak base) + H + H2CO3

• Ampholyte - act as both acid and base

– Water … and many more
Dr.P.J.Samuel
Introduction to pH

Dr.P.J.Samuel
 Introduction to pH
• Normal H+ concentration in blood is 0.00004 meq/L
or 40 neq/L … (most ions are in meq/L)

• machinery of the cells is very sensitive to changes

in H+ ion concentration in ECF

• Concentration of H+ is expressed as
pH (Potential/Power of Hydrogen)
pH = -Log [H+] read as ‘negative log of
concentration of hydrogen ions’
Dr.P.J.Samuel
pH of Body Fluids

Dr.P.J.Samuel
 pH different in different fluids
• Blood pH 7.4
• Art. Blood 7.4 (7.38 – 7.43)
• Venous Blood 7.35 (7.36 – 7.4)
• ISF 7.35
• ICF 6 – 7.4
• Urine 4.5 – 8.0
• Gastric HCl 0.8

8
 Introduction to pH

◼ Normal pH of arterial blood 7.4 i.e.

H+ - 0.00004 meq/L or 40 neq/L
◼ HCO3- in plasma 24-28 meq/L
Dr.P.J.Samuel
Effects of pH change

Dr.P.J.Samuel
 What happens if body is too acidic
•  Ability to absorb minerals & Nutrients
•  Energy Production
•  Ability to repair damaged cells
•  ability to detoxify heavy metals
• Enable tumor cell to thrive
• Susceptible to fatigue & illness
• Affects operation of cellular enzymes ; Excitability
of nerves , muscles ; vital organs like brain & heart
Dr.P.J.Samuel
 What happens if body has alkalosis
• Light headedness, confusion, catatonic stupor,
Coma
• Seizures

• hand tremors, involuntary muscle twitching and

sensations of numbness or tingling in the face, arms
or legs, can lead to tetany

• nausea and vomiting

• Hypokalemia
• Arrhythmias Dr.P.J.Samuel
 pH change

• Normal blood pH (Plasma) 7.4 (40 nEq/L)

• When pH is ↑by 0.3 to 7.7,[H+]=20 nEq/L

• When pH ↓ by 0.3 to 7.1, [H+]= 80 nEq/L

Therefore Acidosis is more dangerous .

Dr.P.J.Samuel
 Prologue to Mechanism
Types of acids in the body
• Volatile Acids
– Can leave solution and enter the atmosphere
– CO2 / H2CO3
– CO2 + H2O H2CO3 H+ + HCO3-
– pCO2 is most important factor in pH of tissues
• Fixed Acids
– Do not leave solution
– Lactic acid / Phosphoric acid etc
– Catabolism of amino acids, nucleic acids,
phospholipids Dr.P.J.Samuel
Source of Imbalance

Dr.P.J.Samuel
 Source of imbalance
Sources of Acids –more significant
• Dietary intake Result in addition of
approx. 1 meq/kg of
– Of acids e.g. acidifying
salts body weight of
nonvolatile acid to
• Cellular Metabolism
the body each day
(70 meq/day for
• Fecal HCO3 loss …
-
most adults)
diarrhoea

CO2 does not add any acid to the body as long as it is

actively breathed out
Dr.P.J.Samuel
 Source of imbalance
Sources of Alkalis –less significant
• Dietary intake
– Of fruits, alkaline salts

• Acid loss … vomiting

Dr.P.J.Samuel
Mechanisms to Balance
H+ ion concentration

Dr.P.J.Samuel
 Mechanism to balance
Defence against H+ concentration
• Chemical buffer system – (temporary)
Within fraction of a second Combination
– Bicarbonate, Phosphate, Protein, with H+
Haemoglobin

• Respiratory system - Within few Reduction of

minutes(short term) Carbonic acid

Reduction of
• Renal system - Slow but very powerful
non-carbonic
acid by H+
Dr.P.J.Samuel elimination
 Mechanism to balance
Chemical buffer system
Consider following equations
• HCl + NaHCO3 NaCl + H2CO3
• H2SO4 + NaHCO3 NaHSO4 + H2CO3
Strong acids converted to weaker acids
Nonvolatile acids converted to volatile acids

Now the volatile acids are removed by other

mechanisms (respiratory/renal).

Dr.P.J.Samuel
 Bicarbonate Buffer system
• Present in large quantities
• Respiratory and renal systems act on this
buffer system
• Most important ECF buffer
• pK = 6.1

CO2+H2O H2CO3 H+ + HCO3-

21
 Bicarbonate Buffer

• NaHCO3 and H2CO3

• Maintain a 20:1 ratio : HCO3- : H2CO3
• HCl + NaHCO3 H2CO3+NaCl
• NaOH + H2CO3 NaHCO3 + H2O
• Henderson Hasselbach Equation

22
 Phosphate Buffer system
• Low activity in ECF
• Better buffer in the ICF, Kidneys and bone
• pK = 6.8
• HPO42- & H2PO4-
• H+ + HPO42- H2PO4-
• OH- + H2PO4- H2O + HPO42-

23
 Proteins Buffer system
• Abundant (in Blood and ISF)
• pK close to 7.4
• Carboxyl group – gives up H+
• Amino group – Accepts H+
• RCOOH RCOO- + H+
• RNH3 + H+ RNH4+

24
 Haemoglobin
• Dissociation of imidazole group
• Less efficient
• pK = 7.7
• But Hb has 38 Histidine residue
• Plenty of Hb present

25
 Isohydric principle
• All buffer systems work together
• H+ shifts from one Buffer system to another

26
 Mechanism to balance
Respiratory / Excretory response
CO2 + H2O H2CO3 H+ + HCO3-

Hyperventilation removes
H+ ion concentrations Kidneys
eliminate or retain
Hypoventilation increases H+ or HCO3- ions
H+ ion concentrationsDr.P.J.Samuel
 Mechanism to balance
Consider the chemical bufferring
HCl + NaHCO3 NaCl + H2CO3
H2SO4 + NaHCO3 NaHSO4 + H2CO3
Respiratory / Excretory response
CO2 + H2O H2CO3 H+ + HCO3-

Removal of nonvolatile acids by chemical buffers uses

up HCO3- thus reducing HCO3- level in the blood. So it
would be more efficient to remove H+ ions as this
adds back the HCO3- used up in the prior process.
Dr.P.J.Samuel
Renal Regulation of
Acid-Base Balance

Dr.P.J.Samuel
 Introduction -Mechanism to balance
Excretory response to Acid-Base Balance
CO2 + H2O H2CO3 H+ + HCO3-

Kidneys
eliminate or retain
H+ or HCO3- ions
Dr.P.J.Samuel
 Introduction – Limiting pH
• Nephron cannot produce a urine pH < 4.5
• This is called Limiting pH .. normally reached in
Collecting Duct

• At this pH the H gradient of tubular fluid to plasma

is 1000 to 1, a concentration gradient against which
further H ion secretion cannot occur unless the
tubular fluid H ion is “tied up” / seized by a buffer…
by HCO3- , HPO42-(dibasic phosphate), NH3

Dr.P.J.Samuel
 Renal Acid Base Regulation
The Mechanism
Kidneys help regulate blood pH
• By excreting acid (H+) – enables the next two below

• By generating HCO3 – adds that which was neutralized

• By reabsorbing HCO3 – that which was filtered

Dr.P.J.Samuel
 Purpose of secretion/excretion of
H+ ions

• Eliminate extra acid

• Contribute normal acid base balance
• Conserve alkali
• Protects from urinary tract infection

Dr.P.J.Samuel
Anion Gap

Dr.P.J.Samuel
 Anion Gap
• Normally … Cations conc. = Anions Conc. … but only a few
are measured in either group.

Dr.P.J.Samuel
 Anion Gap
• With potassium - The anion gap is calculated by subtracting
serum concentrations of chloride and bicarbonate (anions)
from the concentrations of sodium and potassium (cations):
= ([Na+] + [K+]) − ([Cl−] + [HCO3 − ]) = 20 mEq/L

• Without potassium (daily practice) - Because K+ conc. are

very low, they usually have little effect on the calculated
gap. Therefore, omission of K+ widely accepted.
= [Na+] − ([Cl−] + [HCO3−]) = 12 ± 4 mEq/L

Expressed in words, the equation is:

• Anion Gap = Sodium - (Chloride + Bicarbonate)
• (Bicarbonate may also be referred to as "total CO2" or "carbon dioxide".)
Dr.P.J.Samuel
Acid-Base Disorders

Dr.P.J.Samuel
 Acid Base Imbalance
• pH<7.35 – Acidosis
• pH>7.45 – Alkalosis

RESPIRATORY METABOLIC

CO2+H2O H2CO3 H+ + HCO3-

38
 Acid Base Imbalance
• Body’s response to Acid base imbalance
COMPENSATION
• If Cause is Metabolic – Change in ventilation can
help – RESPIRATORY COMPENSATION
• If cause is Respiratory – RENAL COMPENSATION

RESPIRATORY METABOLIC
CO2+H2O H2CO3 H+ + HCO3- 39
 ACIDOSIS
• Principal effect – CNS depression
• Generalized weakness
• Severe acidosis causes
– Disorientation
– Coma
– Death

40
 ALKALOSIS
• Over excitability of Central and Peripheral
Nervous system
• It can cause
– Nervousness
– Muscle spasms or Tetany
– Convulsions
– Loss of consciousness
– Death

41
 Respiratory Acidosis
• Hypercapnea
• pCO2 > 45 mmHg (for simple calculating purposes 40 mmHg)
Cause
• Depression of Resp. Centre
• Emphysema Renal Compensation
• Pulmonary edema • Renal loss of H+
• Pneumothorax • Retain HCO - 3

42
 RESPIRATORY ALKALOSIS
pCO2 < 35mmHg (for simple calculating purposes 40 mmHg)

Cause
• Hyperventilation
• High altitude
• Pulmonary disease Renal compensation
• Congestive heart failure • Conserve H + ions

• Excrete Bicarbonate
ions
43
 METABOLIC ACIDOSIS
HCO3- deficit (<22mEq/L) (for simple calculating purposes 24 meq/L)

Cause
• Loss of HCO3-
Diarrhea/Renal
dysfunction
• Accumulation of acids Respiratory compensation
• Lactic acid • ↑ Ventilation
• Ketone Bodies • If possible Renal
• Failure of kidneys to Excretion of H+ ions
excrete H+ 44
 METABOLIC ALKALOSIS
↑ HCO3- (>26mEq/L) (for simple calculating purposes 24 meq/L)

Cause
• Excess vomiting
– (From stomach)
• Use of diuretics Respiratory compensation
• Severe dehydration • Hypoventilation

45
Analysis of Acid Base Balance
(text book approach)

Dr.P.J.Samuel
 Analysis of Acid Base Balance
(simpler approach)
Step 1 Step 2

Step 3 – See HCO3 levels to confirm

Dr.P.J.Samuel
ACID BASE NOMOGRAM

48
Dr.P.J.Samuel
Dr.P.J.Samuel
Dr.P.J.Samuel
Dr.P.J.Samuel
Siggard Anderson Curve Nomogram

Dr.P.J.Samuel
 At the end of this class u must know
• Introduction to Acid and Base
• Introduction to pH
• Source of imbalance
• Mechanisms to balance H+ ion concentration
• Renal Acid Base Regulation
• Anion Gap
• Acid Base Disorders
Dr.P.J.Samuel