To investigate rate, characteristics of acid-base disturbances in patients with chronic kidney disease stage 4, 5 who were diagnosed for the first time. Subjects and methods: 182 patients with chronic kidney disease stage 4, 5 due to some causes without alkalization or replacement therapy within a month. Assessment of acid-base disturbances based on results of arterial blood gas test according to the criteria of Berend K, which include pH, HCO3 - and PaCO2. Additionally, metabolic acidosis was identified when HCO3 - level < 22 mmol/L and renal tubular acidosis was diagnosed according to the criteria of Yaxlay J (2016) based on urinary pH and HCO3 - . Results: 140 patients (76.9%) had acid-base disturbances with all types according to Berend K, including: Metabolic acidosis (79.3%); respiratory acidosis (3.6%); metabolic alkalosis (1.41%); respiratory alkalosis (13.6%) and mixed acid-base disturbances (2.1%). There were 152 patients (83.5%) with HCO3 - level < 22 mmol/L, in which HCO3 - level decreased mildly (71.1%); moderately (26.3%) and severely (2.6%).
Trang 1ACID-BASE DISTURBANCES IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 4, 5
Nguyen Duc Phat 1 ; Hoang Trung Vinh 2 ; Pham Van Tran 2
SUMMARY
Objectives: To investigate rate, characteristics of acid-base disturbances in patients with chronic kidney disease stage 4, 5 who were diagnosed for the first time Subjects and methods:
182 patients with chronic kidney disease stage 4, 5 due to some causes without alkalization or replacement therapy within a month Assessment of acid-base disturbances based on results of arterial blood gas test according to the criteria of Berend K, which include pH, HCO 3 - and PaCO 2 Additionally, metabolic acidosis was identified when HCO 3
-
level < 22 mmol/L and renal tubular acidosis was diagnosed according to the criteria of Yaxlay J (2016) based on urinary pH and HCO 3
- Results: 140 patients (76-.9%) had acid-base disturbances with all types according
to Berend K, including: Metabolic acidosis (79.3%); respiratory acidosis (3.6%); metabolic alkalosis (1.41%); respiratory alkalosis (13.6%) and mixed acid-base disturbances (2.1%) There were 152 patients (83.5%) with HCO 3
-
level < 22 mmol/L, in which HCO 3
-
level decreased mildly (71.1%); moderately (26.3%) and severely (2.6%) Type 2 of renal tubular acidosis accounted for the highest rate (48.7%), while type 1 accounted for the lowest rate (2.6%) Conclusions: Patients with chronic kidney disease stage 4, 5 had occurence of all types of acid-base disturbances, in which metabolic acidosis accounted for the highest rate Renal tubular
acidosis was also seen in all types, in which type 2 accounted for the highest rate
* Keywords: Chronic kidney disease; Acid-base disturbances; Metabolic acidosis; Renal tubular acidosis
INTRODUCTION
Chronic kidney disease (CKD) is
increasing in all countries, due to many
different causes and causes severe
consequences for patients and society
CKD damages many organs, causing many
disorders of metabolism - endocrine
Disturbances of acid-base balance in
general and metabolic acidosis in particular
are common manifestations, especially
in the late stage of the disease, affect
progression of disease and life of patients
Metabolic acidosis usually occurs when the glomerular filtration rate is less than
25 - 30 mL/min, equivalent to stage 4, 5
of CKD However, it also depends on many factors and is individualized Disturbances of acid-base balance are defined by arterial blood gas Although the concept of disturbances of acid-base balance was proposed by Arrhenius in
1880, so far knowlege of manifestations, causes and progress have remained unclear, incomprehensible and controversial
1 Kiengiang Department of Health
2 103 Military Hospital
Corresponding author: Hoang Trung Vinh (hoangvinh.hvqy@gmail.com)
Date accepted: 14/11/2018
Trang 2Identifying the manifestations of disturbances
of acid-base balance corresponding to
clinical types of disorder as well as
evaluating degree of the disturbances
provide basis of appropriating diagnosis,
treatment and prognosis Therefore, we
conducted this study for purpose: To
investigate rate, characteristics of
acid-base disturbances in patients with CKD
stage 4, 5 who were diagnosed for the
first time
SUBJECTS AND METHODS
1 Subjects
182 patients with CKD stage 4, 5 were
enrolled in our study
* Selected criteria:
+ Causes of CKD: Hypertension,
diabetes mellitus, chronic glomerulonephritis,
chronic pyelonephritis, polycystic kidney
disease
+ Diagnosed with CKD for the first
time
+ Agree with enrolling in the study
* Excluded criteria:
+ Having any combined diseases or acute complications
+ Having combined chronic diseases
or severe complications such as heart failure grade 3, 4; cirrhosis, bronchial asthma, chronic obstructive pulmonary disease, respiratory failure
+ Acute renal failure
2 Methods
* Study design: Prospective, descriptive,
cross-sectional
* Study contents:
+ Ask for history of the disease and clinical manifestations
+ Examine the organs or parts of the body
+ Perform biochemistry test and arteria blood gas test
* Criteria for diagnosis and classifications: Table1: Categories of CKD according to KDIGO (2012)
diseases and risk factors, slow the progression of kidney disease
2
Kidney damage with
Control risk factors and combined diseases, slow the progression of kidney disease
Diagnose and treat complications caused by kidney disease
treatments
(or hemodialysis)
Obligatory substitution therapy (if there is hyperuricemia syndrome)
(Source: KDIGO (2012): Definition and classification of CKD)
Trang 3Table 2: Reference values of arterial blood gas indice tested on the GEM
Prernier 3,000
Table 3: Classification of acid-base disturbances by Berend K
Mixed acid-base disturbances when:
Table 4: Classification of renal tubular acidosis
decreased
Normal or mildly decreased
Normal or mildly to
Primary
defective
position
Impaired
the distal tubule
Reabsorbtion of
proximal tubule
Both proximal and distal tubule injuried
Defects in the ability to produce and secrete amoni ion
* Statistical analysis:
+ SPSS software version 17.0 was used to analyse data
+ Research contents do not violate medical ethics
Trang 4RESULTS
* Distribution of patients by age group
(n = 182):
≤ 40 years old: 19 patients (10.4%);
41 - 50 years old: 21 patients (11.5%);
51 - 60 years old: 37 patients (20.3%);
61 - 70 years old: 61 patients (33.5%);
> 70 years old: 44 patients (24.2%)
* Distribution of patients by CKD causes
(n = 182):
68 patients (37.4%) had hypertension,
16 patients (8.8%) had diabetes mellitus,
59 patients (32.4%) had hypertension
combined to diabetes mellitus, and
39 patients (21.4%) had primary structural
kidney diseases (primary structural kidney
diseases comprise chronic glomerulonephritis,
chronic pyelonephritis, polycystic kidney
disease) Majority of the patients was
hypertensive and/or diabetic patients
Table 5: Rates of acid-base disorders
and types of disorders
(n)
Percentage (%)
Non acid-base
disorders
Rate of acid-base disorders was higher
than rate of non disorders Simple
acid-base disorders accounted for higher rate
compared to mixed disorders
* Distribution of patients with acid-base
disorders by type of disorders (n = 140):
111 patients (79.3%) had metabolic acidosis; 5 patients (3.6%) had respiratory acidosis; 2 patients (1.4%) had metabolic alkalosis; 19 patients (13.6%) had respiratory alkalosis; 3 patients (2.1%) had mixed acid-base disorders Metabolic acidosis accounted for the highest rate
Metabolic alkalosis accounted for the lowest rate
Table 6: Rate and severity of decreased
HCO3- level
Mild decrease (15 - < 22)
Moderate decrease (10 - 14.9)
Severe decrease (< 10)
+ Rate of decreased HCO3- level was higher than that of normal HCO3- level
+ Rate of mildly decreased HCO3- level was the highest, rate of severely decreased HCO3- level was the lowest
* Distribution of patients by types of renal tubular acidosis (n = 152):
Type 1: 4 patients (2.6%); type 2:
74 patients (48.7%); type 3: 34 patients (22.4%); type 4: 40 patients (26.3%)
Type 2 of renal tubular acidosis accounted for the highest rate, type 1 accounted for the lowest rate
Trang 5DISCUSSION
1 General characteristics of patients
Two factors are ages of patients and
CKD causes that can impact on the
appearance and severity of acid-base
disturbances Ages of patients ranged
from 28 to 79, in which age group of 61 -
70 accounted for the highest rate and age
group of ≤ 40 accounted for the lowest
rate Age may be a factor related to
occurrence and severity of acid-base
disorders In older patients, acid-base
disturbances seem to occur more frequent
and be at more severe degree Age is
related to the causes of CKD, in which
hypertension and diabetes mellitus are the
two diseases occuring with the highest rate,
they can appear alone or in combination
In our study, hypertension was found in
127 cases, accounting for 69.8%, while
diabetes was found in 75 cases, accounting
for 41.2% Primary renal structural diseases,
including chronic glomerulonephritis, chronic
pyelonephritis, polycystic kidney disease
were seen with the lower rate (21.4%)
2 Acid-base disorders in patients with CKD stage 4, 5
According to the classification of Berend K, our study indicated that 76.9%
of patients had acid-base disorders, in which majority was simple acid-base disorders (97.7%) Among patients with base imbalance, all types of acid-base disturbances were seen, however metabolic acidosis was reported with the highest rate (79.3%), metabolic alkalosis accounted for the lowest rate (1.4%) Respiratory alkalosis and respiratory acidosis were found in 13.6% and 3.6% of patients, respectively There were
3 patients (2.1%) who had mixed acid-base disturbances Our results showed that all types of acid-base disturbances can be seen in patients with CKD stage 4,
5 due to some causes, in which metabolic acidosis was the most popular rate, some forms of all-cause alkalosis, although metabolic acidosis is the most common Our results were similar to those of many authors reported
Table 7: Rate of metabolic acidosis by some authors
acidosis
Our study (2018)
CKD stage 4, 5 without alkalization or renal replacement therapy
accounted for 71.1%
Vu Thi Thu Huong (2014)
[1]
CKD with all stages without renal replacement therapy
42.1% matched criteria for metabolic acidosis, 60.3% of patients had
Stage 1: 1.1%; stage 2: 2.7%; stage 3a:
27.9%; stage 3b: 19.2%; stage 4: 9.4%;
stage 5: 1.4%
Trang 6Costa de Oliveira (2015) [5]
End stage renal disease (ESRD) treated by maintenance hemodialysis
94.7%, in which 10.3% of patients had
-: 20.18 ± 4.93 mmol/L
hemodialysis
< 22 mmol/L
If diagnosis of metabolic acidosis only
based on HCO3- level < 22 mmol/L, our
study showed 152 cases (83.5%) having
metabolic acidosis, which was higher than
that based on the criteria of Berend K,
which simultaneously based on both pH
and HCO3- In fact, the rate of metabolic
acidosis is even higher Majority of
authors also identified metabolic acidosis
only based on HCO3- level < 22 mmol/L
[9, 10] Among patients with HCO3- level
< 22 mmol/L, 71.1% of patients with mild
decrease, 26.3% with moderate decrease
and only 2.6% with severe decrease This
classification was also used by Costa de
Oliveira C.M for evaluation [5] Patients
with metabolic acidosis were classified
into injured types related to tubular renal,
by which type 2 of renal tubular acidosis
caused by defect in proximal tubule
accounted for the highest rate (48.7%),
while type 1 caused by defect of distal
tubule accounted for the lowest proportion
(2.6%)
CONCLUSIONS
By studying 182 patients with chronic
kidney disease stage 4, 5 who were
diagnosed for the first time, we had the
following comments:
+ 76.9% of patients had acid-base disturbances, in which 97.9% were simple acid-base disorders
+ Among patients with acid-base disturbances, all types of acid-base disturbances were seen with the different rates, including: Metabolic acidosis with the highest rate (79.3%); respiratory alkalosis 13.6%; respiratory acidosis 3.6%; metabolic alkalosis 1.7% and mixed acid-base disorders 2.1%
+ Among patients with decreased HCO3- level corresponding to criteria for metabolic acidosis, patients with mild decrease accounted for the highest rate (71.1%); moderate decrease accounted for 26.3%; severe decrease accounted for the lowest rate
+ Type 2 of renal tubular acidosis was seen with the highest rate (48.7%), followed
by type 4 (26.3%); type 3 (22.4%) Type 1 was recorded with the lowest rate (2.6%)
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