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%).
Journal of military pharmaco-medicine n09-2018 ACID-BASE DISTURBANCES IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 4, Nguyen Duc Phat1; Hoang Trung Vinh2; Pham Van Tran2 SUMMARY Objectives: To investigate rate, characteristics of acid-base disturbances in patients with chronic kidney disease stage 4, who were diagnosed for the first time Subjects and methods: 182 patients with chronic kidney disease stage 4, 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%) Type of renal tubular acidosis accounted for the highest rate (48.7%), while type accounted for the lowest rate (2.6%) Conclusions: Patients with chronic kidney disease stage 4, had occurence of all types of acidbase disturbances, in which metabolic acidosis accounted for the highest rate Renal tubular acidosis was also seen in all types, in which type 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, 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 Kiengiang Department of Health 103 Military Hospital Corresponding author: Hoang Trung Vinh (hoangvinh.hvqy@gmail.com) Date received: 19/09/2018 Date accepted: 14/11/2018 121 Journal of military pharmaco-medicine n09-2018 Identifying 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 acidbase disturbances in patients with CKD stage 4, who were diagnosed 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 Methods SUBJECTS AND METHODS Subjects 182 patients with CKD stage 4, 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 * 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) Stage Description Kiney damage with normal or high GFR Kidney damage with mildly decreased GFR GFR (mL/min/1.73 m ) Recommendation ≥ 90 Diagnose and treat combined diseases and risk factors, slow the progression of kidney disease 60 - 89 Control risk factors and combined diseases, slow the progression of kidney disease Moderately decreased GFR 30 - 59 Diagnose and treat complications caused by kidney disease Severely decreased GFR 15 - 29 Prepare treatments Kidney failure < 15 (or hemodialysis) replacement Obligatory substitution therapy there is hyperuricemia syndrome) (Source: KDIGO (2012): Definition and classification of CKD) 122 kidney (if Journal of military pharmaco-medicine n09-2018 Table 2: Reference values of arterial blood gas indice tested on the GEM Prernier 3,000 Indicex Unit Normal value pH 7.38 - 7.42 PaCO2 mmHg 38 - 42 mmol/L 22 - 26 PaO2 mmHg 83 - 108 tCO2 mmol/L 22 - 29 BE mmol/L (-2) - (+2) % 94 - 98 HCO3 - SaO2 Table 3: Classification of acid-base disturbances by Berend K Types of disorders - pH HCO3 (mmol/L) Metabolic acidosis < 7.38 < 22 Respiratory acidosis < 7.38 Metabolic alkalosis > 7.42 Respiratory alkalosis > 7.42 PaCO2 (mmHg) > 42 > 26 < 38 Mixed acid-base disturbances when: Metabolic acidosis > 42 Metabolic alkalosis < 38 Respiratory acidosis < 22 Respiratory alkalosis > 26 Table 4: Classification of renal tubular acidosis Parameters Urine pH - HCO3 (mmol/L) Serum K + Primary defective position Type Type Type Type > 5.5 < 5.5 < 10 > 15 10 - 15 > 15 Mildly to severely decreased Normal or mildly decreased Normal or mildly to severely decreased Increased Impaired + secretion of H in the distal tubule Reabsorbtion of HCO3 in the proximal tubule Both proximal and distal tubule injuried Defects in the ability to produce and secrete amoni ion < 5.5 * Statistical analysis: + SPSS software version 17.0 was used to analyse data + Research contents not violate medical ethics 123 Journal of military pharmaco-medicine n09-2018 RESULTS * 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 Manifestation Quantity (n) Percentage (%) Non acid-base disorders 42 23.1 Acid-base disorders 140 76.9 Simple disorders 137 97.9 Mixed disorders 2.1 Rate of acid-base disorders was higher than rate of non disorders Simple acidbase disorders accounted for higher rate compared to mixed disorders * Distribution of patients with acid-base disorders by type of disorders (n = 140): 124 111 patients (79.3%) had metabolic acidosis; patients (3.6%) had respiratory acidosis; patients (1.4%) had metabolic alkalosis; 19 patients (13.6%) had respiratory alkalosis; 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 Quantity (n) Percentage (%) - 30 16.5 HCO3 < 22 mmol/L - 152 83.5 Mild decrease (15 - < 22) 108 71.1 Moderate decrease (10 - 14.9) 40 26.3 Severe decrease (< 10) 2.6 - HCO3 level HCO3 ≥ 22 mmol/L + 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: patients (2.6%); type 2: 74 patients (48.7%); type 3: 34 patients (22.4%); type 4: 40 patients (26.3%) Type of renal tubular acidosis accounted for the highest rate, type accounted for the lowest rate Journal of military pharmaco-medicine n09-2018 DISCUSSION 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%) Acid-base disorders in patients with CKD stage 4, 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 acid-base imbalance, all types of acidbase 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 patients (2.1%) who had mixed acidbase disturbances Our results showed that all types of acid-base disturbances can be seen in patients with CKD stage 4, 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 Authors Participants Rate and feature of metabolic acidosis CKD stage 4, without alkalization or renal replacement therapy 79.3%, HCO3 level of 15 - 22 mmol/L accounted for 71.1% CKD with all stages without renal replacement therapy 42.1% matched criteria for metabolic acidosis, 60.3% of patients had HCO3 < 22 mmol/L CKD stage 3, Stage 3: 2.3 - 13%; stage 4: 19 - 37% Harambat J (2017) [3] CKD stage 3, 4, Stage 3: 43%; stage 4: 60%; stage 5: 45% Kovesdy C.P (2012) [4] CKD with all stages Stage 1: 1.1%; stage 2: 2.7%; stage 3a: 27.9%; stage 3b: 19.2%; stage 4: 9.4%; stage 5: 1.4% Our study (2018) Vu Thi Thu Huong (2014) [1] Kraut J.A (2016) [2] - 125 Journal of military pharmaco-medicine n09-2018 End stage renal disease (ESRD) treated by maintenance hemodialysis 94.7%, in which 10.3% of patients had HCO3 < 15 mmol/L; 84.2% of patients had HCO3 : 15 - 21.9 mmol/L Sajgure A.D (2017) [6] ESRD treated by maintenance hemodialysis 62.8%, HCO3 : 20.18 ± 4.93 mmol/L Liborio A.B (2013) [7] ESRD treated by maintenance hemodialysis 90% of patients had HCO3 level < 22 mmol/L Sternlicht H (2013) [8] CKD stage 3, Stage 3: 5%; stage 4: 33% Costa de Oliveira (2015) [5] - - + 76.9% of patients had acid-base disturbances, in which 97.9% were simple acid-base disorders 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 of renal tubular acidosis caused by defect in proximal tubule accounted for the highest rate (48.7%), while type caused by defect of distal tubule accounted for the lowest proportion (2.6%) + Type of renal tubular acidosis was seen with the highest rate (48.7%), followed by type (26.3%); type (22.4%) Type was recorded with the lowest rate (2.6%) CONCLUSIONS REFERENCE By studying 182 patients with chronic kidney disease stage 4, who were diagnosed for the first time, we had the following comments: Vu Thi Thu Huong Survey of some arterial blood gas parameters in patients with chronic renal failure Master Thesis in Medicine Vietnam Military Medical University 2014 126 + 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 acidbase 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 Journal of military pharmaco-medicine n09-2018 Kraut J.A, Madias N.E Metabolic acidosis of CKD: An update AJKD 2016, 67 (2), pp.307-317 Harambat J, Kunzmann K, Azukaitis K et al Metabolic acidosis is common and associates with disease progression in children with chronic kidney disease Kidney Int 2017, 92 (6), pp.1507-1514 Chen W, Abramowitz M.K Treatment of metabolic acidosis in patients with CKD Am J Kidney Dis 2014, 63 (2), pp.311-317 Costa de Olivevira C.M, Lustosa C, Cristino E.F et al Metabolic acidosis and its association with nutritional status in hemodialysis J Bras Nefrol 2015, 37 (4), pp.1/10-7/10 Sajgure A.D, Dighe T.A, Korpe J.S et al The relationship between metabolic acidosis and nutritional parameters in patients on hemodialysis Indian J Nephrol 2017, 27 (3), pp.190-194 Liborio A.B, Leite T.T Disturbances in acid-base balance in patients on hemodialysis Hemodialysis INTECH 2013, Chapter 10, pp.211-224 Sternlicht H, Melamed M.L Alkalinization to retard progression of chronic kidney failure Nutritional Management of Renal Disease 2013, Chapter 18, pp.257-262 Raphael K.L Metabolic acidosis and subclincal metabolic acidosis in CKD JASN 2018, 29 (2), pp.376-382 10 Goraya N, Simoni J, Jo C.H et al A comparison of treating metabolic in CKD stage hypertensive kidney disease with fruits and vegetables or sodium bicarbonate Clin J Am Soc Nephrol 2013, (3), pp.371-381 127 ... structural diseases, including chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease were seen with the lower rate (21.4%) Acid-base disorders in patients with CKD stage 4, According... associates with disease progression in children with chronic kidney disease Kidney Int 2017, 92 (6), pp. 150 7- 151 4 Chen W, Abramowitz M.K Treatment of metabolic acidosis in patients with CKD Am J Kidney. .. of patients had HCO3 < 22 mmol/L CKD stage 3, Stage 3: 2.3 - 13%; stage 4: 19 - 37% Harambat J (2017) [3] CKD stage 3, 4, Stage 3: 43%; stage 4: 60%; stage 5: 45% Kovesdy C.P (2012) [4] CKD with