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Acidosis & alkalosis ´ëÀå°æ Á¤¸®

1. severe acidosis°¡ ½Åü¿¡ ¹ÌÄ¡´Â ¿µÇâ

1) cardiovascular

¼öÃà·Â °¨¼Ò, arterial vasodilation, venoconstriction, blood volume centralization

pulmonary vascular resistance¡è, BP¡é, hepatic & renal blood flow¡é

arrhythmia threshold°¨¼Ò, catecholamine¿¡ ´ëÇÑ ¹ÝÀÀ °¨¼Ò

2) respiratory

hyperventilation, dyspnea

3) metabolic

metabolic demands¡è, insulin resistance¡è, anaerobic glycolysis¾ïÁ¦

ATP synthesis¡é, hyperkalemia, protein degradation¡è

4) cerebral

metabolism & cell-volume regulation¡é

obtundation & coma

2. urine acidification Æò°¡¹æ¹ý

urine pH, urine anion gap, urine osmolar gap

3. ½ÅºÎÀü¶§ »ý±â´Â metabolic acidosis ±âÀü

½ÅºÎÀü Ãʱ⿡ nephron mass°¨¼Ò·Î NH3»ý¼ºÀÌ °¨¼ÒµÇ¾î hyperchloremic acidosis°¡

»ý±ä´Ù.

½ÅºÎÀüÀÌ ÁøÇàÇÔ¿¡ µû¶ó organic anionÃàÀûµÇ¸é¼­ high AG metabolic acidosis·Î ÁøÇà

serum HCO3-°¡ °¨¼ÒÇÏÁö¸¸ 15 mEq/LÀÌÇϷδ ¶³¾îÁöÁö ¾Ê´Âµ¥ ÀÌ´Â boneÀÇ calcium

carbonateµîÀÌ buffer·Î ÀÛ¿ëÇϱ⠶§¹®ÀÌ´Ù.

½ÅºÎÀü¶§ HCO3-¸¦ 20-24 mmol/L·Î À¯ÁöÇϱâ À§ÇØ alkali tx°¡ ÇÊ¿äÇѵ¥

sodium citrate´Â À§Àå°ü¿¡¼­ aluminumÈí¼ö¸¦ Áõ°¡½ÃŰ¹Ç·Î, aluminumÇÔÀ¯ Á¦»êÁ¦¿Í

°°ÀÌ Åõ¿©Çϸé aluminumÁßµ¶ÀÇ À§ÇèÀÌ ÀÖÀ¸¹Ç·Î ÁÖÀÇÇØ¾ß ÇÑ´Ù.

4. effective osmolality

= 2(Na+K) + glu/18

5. osmolar gap = measured osm - calculated osm

6. high AG metabolic acidosis¸¦ ÀÏÀ¸Å°´Â ¾à¹°

salicylate, methanol, ethylene glycol, paraldehyde

cf. hyperchloremic metabolic acidosis + hyperkalemiaÀÏÀ¸Å°´Â ¾à¹°

: K-sparing diuretics, pentamidine, ACEI, NSAIDs, cyclosporine, trimethoprim

7. high AG metabolic acidosis¿øÀÎ

lactic acidosis, ketoacidosis, drug(salicylate, ethylene glycol, methanol)

renal failure(acute and chronic)

8. ethylene glycol poisoning

s-osmolarity¡è, urine oxalate crystal, ATN(proteinuria, oliguria, anuria)

ethanol·Î Ä¡·á

9. alcoholic ketoacidosisÄ¡·á : normal saline IVÇÏ¿© volume expansion½ÃŲ´Ù.

insulinÀº ±Ý±âÀ̸ç K, P, Mg, vitµîÀ» º¸ÃæÇÑ´Ù.

10. urine anion gap = (Na + K) - Cl

hypercholremic acidosisȯÀÚ¸¦ Æò°¡Çϴµ¥ À¯¿ëÇÏ´Ù.

(+) : renal tubular disorder

(-) : extrarenal cause

11. metabolic acidosis¿¡¼­ÀÇ urine net charge(UNC)

renal or nonrenal hyperchloremic acidosis¸¦ °¨º°ÇÏ´Â ¹æ¹ýÀÌ´Ù.

RTA¿¡¼­´Â NH4+ ÇÕ¼º ¹× ¹è¼³ °¨¼Ò·Î UNC°¡ Áõ°¡ÇÑ´Ù.

¼³»ç·Î ÀÎÇÑ metabolic acidosis¶§´Â NH4+ÇÕ¼º ¹× ¹è¼³ Áõ°¡·Î UNC°¡ °¨¼ÒÇÑ´Ù.

12. amphoterin B -> typeI RTAÀÏÀ¸Å´

13. metabolic acidosis¸¦ Ä¡·áÇϱâ À§ÇØ sodium bicarbonate¸¦ Åõ¿©ÇÒ¶§ÀÇ ºÎÀÛ¿ë

: volume expansion(pul. edema, hypertension ¾ÇÈ­), hypocalcemia, hypokalemia

metabolic & respiratory alkalosis

14. metabolic acidosis + hypokalemia

type I, II RTA, diarrhea, DKA, carbonic anhydrase inhibitor

15. distal RTA

Calcium phosphate, nephrocalcinosisµîÀÌ Àß ¹ß»ýÇÏ¸ç ±× ¿øÀÎÀ¸·Î´Â hypercalciuria,

alkaline urine, low level of citrate µîÀÌ´Ù.

urine pH°¡ ³ô¾Æ¼­ ü³»¿¡¼­ »ý¼ºµÈ total acidº¸´Ù net acid excretionÀÌ °¨¼ÒµÇ¾î ÀÖ´Ù.

acidosis¿Í hypercalciuria°¡ ±³Á¤µÉ¶§±îÁö 1-3 mEq/kgÀÇ alkaliÄ¡·á°¡ ¿ä±¸µÈ´Ù.

´ëºÎºÐ K supplement´Â ÇÊ¿äÄ¡ ¾Ê´Ù.

16. distal RTA¿¡¼­ ½Å°á¼®ÀÌ Àß ¹ß»ýÇÏ´Â ±âÀü

hypercalciuria & hyperphosphaturia

urine pH¡è

hypocituria

17. Fanconi syndrome: type2 RTA, glycosuria + normal serum glucose,

hypophosphatemia hypouricemia, hypokalemia, aminoaciduria

18. diuretics¿¡ ÀÇÇØ metabolic alkalosis°¡ »ý±â´Â ±âÀü

ECF volume°¨¼Ò, secondary hyperaldosteornism, K deficiency, diureticsÀÇ Á÷Á¢Àû ÀÛ¿ë

19. metabolic alkalosis°¡ Áö¼ÓÇϵµ·Ï ÇÏ´Â ÀÎÀÚ

1) proximal bicarbonate reabsorption¡è

ECF volume contraction, K depletion, hypercapnia

2) net bicarbonate regeneration

distal salt delivery¡è, mineralocorticoid excess

20. Bartter's syndrome Ä¡·á

NSAIDs, aldactone, ACE inhibitor, ¥â-blocker

21. RTAÀÇ °øÅëµÈ Ư¡: hyperchloremic metabolic acidosis

1) type 1(distal) RTA: distal tubule¿¡¼­ acidificationÀå¾Ö·Î alkaline urine¸¸ ³ª¿È

lumen-> blood·Î H+ back diffusionµÇ¾î lumen³» H+¡é

³ôÀº pH gradient¿¡µµ ºÒ±¸Çϰí H+ transport¡¿

=> urine pH°¡ 5.5ÀÌÇÏ·Î ¶³¾îÁöÁö ¾Ê´Â´Ù.

chronic acidosis -> 2ndary hyperparathyroidism, renal hypercalciuria

-> calcium phosphate stone, nephrocalcinosis°¡ Àß »ý±ä´Ù.

vit D»ý¼º°¨¼Ò·Î ÀÎÇÏ¿© osteomalacia°¡ »ý±âÁö¸¸ bone disease´Â type 2 RTA¿¡¼­ ´õ

¹®Á¦

oral NH4Cl loading test½ÃÇà½Ã systemic acidosis°¡ ¾ÇÈ­µÇ¸ç urine pH´Â 5.5ÀÌÇÏ·Î

³»·Á°¡Áö ¾Ê´Â´Ù.

2) type 2(proximal) RTA ; proximal tubule¿¡¼­ bicarbonate reabsorptionÀå¾Ö

acidosis½Ã Á¤»ó acid urine

Á¤»ó plasma bicarbonate³óµµ½Ã renal bicarbonate wasting¡è

potassium wastingÀÌ µ¿¹ÝµÇ¸ç alkali¸¦ ÁÖ¸é wastingÀÌ ´õ Áõ°¡ÇÑ´Ù.

oral NH4Cl loading test½Ã urine pH°¡ 5.5ÀÌÇÏ·Î ¶³¾îÁø´Ù.

Ưº°ÇÑ Ä¡·á´Â ÇÊ¿ä¾øÀ¸³ª acidosis°¡ ½ÉÇÒ°æ¿ì¿£ bicarbonate¸¦ Åõ¿©ÇÑ´Ù.

±×·¯³ª À̶§ potassiumµµ °°ÀÌ ÁÖ¾î¾ß ÇÑ´Ù.

thiazide + low salt diet

Fanconi syndrome°ú ¿¬°ü

3) type 4 RTA

distal nephronÀÇ aldosterone deficiency or aldosterone antagonism

-> hyperkalemia, hyperchloremic metabolic acidosis

22. type 4 RTA°¡ Àß »ý±â´Â »óȲ

i) diabetic nephropathy

ii) nephrosclerosis from hypertension

iii) chronic tubulointerstitial nephropathy

23. type 2 RTA ¿øÀÎ

dysproteinemia, heavy metal intoxication, vit D deficiency or resistance

cancer chemotherapy(ifosfamide), acetazolamide,

genetic ds(Wilson's disease, hereditary fructose intolerance)

Renal physiology & Pathophysiology

1. glomerular microcirculation¿¡¼­ vasodilator

: PGE2, PGI2, NO, ANP

2. contrast nephropathy, cyclosporine nephropathy¿¡¼­ intrarenal vasoconstriction°ú

mesangial cell contractionÀ» ÀÏÀ¸Å°´Â ¹°Áú? endothelin

3. ¼Õ»óµÈ renal tubular cellÀÇ Àç»ý¿¡ °ü¿©ÇÏ´Â growth factor

: EGF, HGF(hepatocyte-GF), IGF

4. ½ÅÀå»ý¸®

1) PTH´Â proximal tubule¿¡ ÀÛ¿ëÇÏ¿© CaÀº Èí¼öÇϰí, P¹è¼³À» Áõ°¡½ÃŲ´Ù.

2) 1,25(OH)2vitD3´Â Àå¿¡¼­ Ca, PÈí¼ö¸¦ Áõ°¡½Ã۰í, bone¿¡¼­ CaÈí¼ö¸¦ ÃËÁøÇÑ´Ù.

3) »ç±¸Ã¼¿¡¼­ ¿©°úµÈ bicarbonate, amino acids, glucose, phosphateÀÇ ´ëºÎºÐÀº

proximal tubule¿¡¼­ ÀçÈí¼öµÈ´Ù.

4) proximal tubuleÀÇ pars recta´Â organic solute transport¿Í ¹«°üÇÏ°Ô active electrogenic

sodium transport¸¦ ÇÑ´Ù.

5) distal tubule°ú collecting duct¿¡¼­ Na reabsorptionÀº thiazide¿¡ ÀÇÇØ ¾ïÁ¦µÈ´Ù.

6) furosemideÀÇ ÀÛ¿ëºÎÀ§´Â Henle's loopÀÇ thick ascending limbÀÇ Na:K:2Cl cotransport

mxÀÌ´Ù.

5. cortical collecting duct¿¡ ÁÖ·Î Á¸ÀçÇϸç aldosteroneÀÇ targetÀÌ µÇ´Â ¼¼Æ÷: principle cell

6. ÀÌ´¢Á¦

1) acetazolamide´Â proximal tubule¿¡ ÀÛ¿ëÇÏ´Â ÀÌ´¢Á¦·Î type 2 RTA¸¦ À¯¹ßÇÒ¼ö ÀÖ´Ù.

2) thiazide´Â distal tubule¿¡ ÀÛ¿ëÇϸç GFRÀÌ 50%´Â ³Ñ¾î¾ß È¿°ú°¡ ÀÖ´Ù.

7. Ç÷¾ÐÃøÁ¤

ÀϹÝÀûÀ¸·Î sitting position¿¡¼­ ÃøÁ¤Çϳª ´©¿ö¼­ Àê¶§´Â 2-3 mmHgÁ¤µµ ´õ ³ô°Ô ÃøÁ¤µÈ´Ù.

Ç÷¾Ð°èÀÇ cuff¸¦ ÀÛÀº °ÍÀ» ¾²¸é ¼öÃà±â Ç÷¾ÐÀÌ ½ÇÁ¦º¸´Ù ³ô°Ô ³ª¿Â´Ù.

ûÁø±â·Î brachial artery¸¦ ³Ê¹« ¼¼°Ô ´©¸£¸é À̿ϱâ Ç÷¾ÐÀÌ ½ÇÁ¦º¸´Ù ³·°Ô ³ª¿Ã¼ö ÀÖ´Ù.