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CPC Conference February 8, 2005

CPC Conference February 8, 2005. James P. Knochel, MD. Did this patient have alcoholic ketoacidosis?. Acute metabolic acidosis and CNS syndrome could result from AKA and thiamine deficiency. Ruled out by lack of ketones and normal lactate in blood Treat with thiamine anyway.

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CPC Conference February 8, 2005

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  1. CPC Conference February 8, 2005 James P. Knochel, MD

  2. Did this patient have alcoholic ketoacidosis? • Acute metabolic acidosis and CNS syndrome could result from AKA and thiamine deficiency. • Ruled out by lack of ketones and normal lactate in blood • Treat with thiamine anyway

  3. Was this patient phosphorus deficient? • Intake? No supplement • 100 lb. Weight loss • Malabsorption? • CHO yes! • Fat? • Serum P = 2.4 (despite acidosis), Mg++ 1.2, Ca++ normal

  4. Renal Excretion of Acid in Normal Persons Three renal mechanisms: • Acidification of urine • Na2H PO4 + H+ NaH2PO4 (Na _____H exchange) • NH3 + H+NH4

  5. What does PO4 deficiency do to acid-base balance? Urine PO4 falls to zero: Therefore no Na2HP4 + H+ NaH2PO4 Renal NH3 production falls Therefore decrease NH3 + H  NH4

  6. PO4 Deficiency in Normal Person Causes • Hypercalciuria • Hypercalcemia under certain conditions • Hydrogen exchanged for bone CO3 • No net change in acid/base status • Dependent on PTH, Mg and Vit D

  7. PO4 Deficiency in Patient with Unresponsive Bone • No change in Ca++ excretion • No bone buffering • No avenue to excrete metabolic acid • Metabolic acidosis results • Reported in lactase deficiency and Ricketts

  8. Did phosphorus deficiency in this patient contribute to metabolic acidosis? • Mg deficiency suppresses bone mobilization • PTH deficiency suppresses bone mobilization • Vit D deficiency suppresses bone mobilization

  9. D-lactic acidosis Clinical Syndrome • Metabolic acidosis with anion gap • Neurological symptoms • Nystagmus, ophthalmoplegia, ataxia, confusion, inappropriate behavior

  10. D-lactic acidosis • Short bowel syndrome with intact colon • Ischemic bowel • Carbohydrate load  colon pH (scfas and acetate) •  Colon pH  bacterioides,lactobacilli, etc • Acid tolerant flora produces D-lactic acid • D-lactic acid absorbed and metabolized

  11. Factors other than metabolic acidosis in this case • Hypernatremia, hyperchloremia with very low BUN and creatinine • ? Nephrogenic DI due to K+ deficienty • K+ = 2.4 despite metabolic acidosis? • Poor intake, chronic diarrhea • Polyuria despite volume depletion • No K+ supplements

  12. Mystery lab test was probably D-lactate

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